Provider Demographics
NPI:1558378208
Name:SHELBY DENTAL ARTS, INC.
Entity Type:Organization
Organization Name:SHELBY DENTAL ARTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-342-4566
Mailing Address - Street 1:70 WEST SMILEY AVE.
Mailing Address - Street 2:P.O.BOX 210
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1326
Mailing Address - Country:US
Mailing Address - Phone:419-342-4566
Mailing Address - Fax:419-347-6617
Practice Address - Street 1:70 W SMILEY AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1056
Practice Address - Country:US
Practice Address - Phone:419-342-4566
Practice Address - Fax:419-347-6617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH157651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty