Provider Demographics
NPI:1215006879
Name:SHELLY, TOM (DDS, MS)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:SHELLY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3958
Mailing Address - Country:US
Mailing Address - Phone:515-573-8351
Mailing Address - Fax:515-576-3513
Practice Address - Street 1:902 2ND AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-3958
Practice Address - Country:US
Practice Address - Phone:515-573-8351
Practice Address - Fax:515-573-3513
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA57961223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0186973Medicaid