Provider Demographics
NPI:1487215851
Name:SIDHU, SHELLEY (DDS)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:SIDHU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 GALLAGHER DR APT 320
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-3126
Mailing Address - Country:US
Mailing Address - Phone:612-222-2644
Mailing Address - Fax:
Practice Address - Street 1:4021 BENJAMIN DR WOODBURY
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-5512
Practice Address - Country:US
Practice Address - Phone:763-515-2593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND142251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice