Provider Demographics
NPI:1104372556
Name:GARY M SHELLERUD DDS
Entity Type:Organization
Organization Name:GARY M SHELLERUD DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHELLERUD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-838-4321
Mailing Address - Street 1:508 W 6TH AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2730
Mailing Address - Country:US
Mailing Address - Phone:509-838-4321
Mailing Address - Fax:509-838-4618
Practice Address - Street 1:508 W 6TH AVE STE 208
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2730
Practice Address - Country:US
Practice Address - Phone:509-838-4321
Practice Address - Fax:509-838-4618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA56781223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124163068OtherNPI