Provider Demographics
NPI:1558896472
Name:BERGHOLCS, SHELLEY CHRISTINE (RDH, BASDH)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:CHRISTINE
Last Name:BERGHOLCS
Suffix:
Gender:F
Credentials:RDH, BASDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 PEACHTREE RD NW
Mailing Address - Street 2:APT. 1902
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-5107
Mailing Address - Country:US
Mailing Address - Phone:813-944-7522
Mailing Address - Fax:
Practice Address - Street 1:2828 PEACHTREE RD NW
Practice Address - Street 2:#1902
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-5107
Practice Address - Country:US
Practice Address - Phone:813-944-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH9701124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist