Provider Demographics
NPI:1275686222
Name:SHELLIE, ROLAND G (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:G
Last Name:SHELLIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E ROBERTSON AVE
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-2928
Mailing Address - Country:US
Mailing Address - Phone:254-547-8442
Mailing Address - Fax:254-547-8555
Practice Address - Street 1:202 E ROBERTSON AVE
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-2928
Practice Address - Country:US
Practice Address - Phone:254-547-8442
Practice Address - Fax:254-547-8555
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX97011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9701OtherBLUECROSSBLUESHIELD
TX824603OtherUNITED CONCORDIA
TXTX9701OtherDELTA COMPANIES