Provider Demographics
NPI:1588676605
Name:SHELTON, JEREMIAH RAYMOND (DDS)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:RAYMOND
Last Name:SHELTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 HARRISON AVE STE B5
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3356
Mailing Address - Country:US
Mailing Address - Phone:304-637-9899
Mailing Address - Fax:304-637-0555
Practice Address - Street 1:1513 HARRISON AVE STE B5
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3356
Practice Address - Country:US
Practice Address - Phone:304-637-9899
Practice Address - Fax:304-637-0555
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037470122300000X
WV37121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist