Provider Demographics
NPI:1407857428
Name:SHELBOURNE, COURTNEY W (DMD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:W
Last Name:SHELBOURNE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 RUTLEDGE AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5817
Mailing Address - Country:US
Mailing Address - Phone:843-853-5859
Mailing Address - Fax:843-853-5861
Practice Address - Street 1:198 RUTLEDGE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5817
Practice Address - Country:US
Practice Address - Phone:843-853-5859
Practice Address - Fax:843-853-5861
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9641Medicaid
SCU88909Medicare UPIN