Provider Demographics
NPI:1154661247
Name:GODINA, SHELLIE ANN
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:ANN
Last Name:GODINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58724 FAWN RIVER CT
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-6200
Mailing Address - Country:US
Mailing Address - Phone:574-238-5470
Mailing Address - Fax:
Practice Address - Street 1:422 N BENTON ST
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:46543-9732
Practice Address - Country:US
Practice Address - Phone:574-642-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011803A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist