Provider Demographics
NPI:1366010415
Name:SHELTON, JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SHELTON
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 1:5527 E 107TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7090
Mailing Address - Country:US
Mailing Address - Phone:918-810-5645
Mailing Address - Fax:
Practice Address - Street 1:150 E, OK-33
Practice Address - Street 2:
Practice Address - City:PERKINS
Practice Address - State:OK
Practice Address - Zip Code:74059
Practice Address - Country:US
Practice Address - Phone:405-939-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK74271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice