Provider Demographics
NPI:1508131806
Name:JOUBERT, SHELLY D (RDH)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:JOUBERT
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 1:10902 IDAHO AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3827
Mailing Address - Country:US
Mailing Address - Phone:612-877-1788
Mailing Address - Fax:
Practice Address - Street 1:1700 WEST HIGHWAY 36
Practice Address - Street 2:SUITE 860
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-778-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH9056124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist