Provider Demographics
NPI:1487840070
Name:SHELTON DENTAL PA
Entity Type:Organization
Organization Name:SHELTON DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GODFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-622-3614
Mailing Address - Street 1:192 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1200
Mailing Address - Country:US
Mailing Address - Phone:973-622-3614
Mailing Address - Fax:973-792-0820
Practice Address - Street 1:573 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1215
Practice Address - Country:US
Practice Address - Phone:973-622-3614
Practice Address - Fax:973-792-0820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI107061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2639700Medicaid