Provider Demographics
NPI:1417228404
Name:KELLERBY, SHASTA MARIE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SHASTA
Middle Name:MARIE
Last Name:KELLERBY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 BROOK VIEW CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81503-4808
Mailing Address - Country:US
Mailing Address - Phone:970-260-6144
Mailing Address - Fax:
Practice Address - Street 1:195 W 14TH
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-4700
Practice Address - Country:US
Practice Address - Phone:970-625-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904683124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist