Provider Demographics
NPI:1336280957
Name:SELF, SHELLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:SIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9902 NE MONSAAS RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1103
Mailing Address - Country:US
Mailing Address - Phone:360-464-0990
Mailing Address - Fax:
Practice Address - Street 1:19365 7TH AVE NE
Practice Address - Street 2:SUITE D108
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7441
Practice Address - Country:US
Practice Address - Phone:360-779-7115
Practice Address - Fax:360-779-3990
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000102561223G0001X
WADE102561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2035573Medicaid
WA1008098Medicaid