Provider Demographics
NPI:1629423884
Name:HUNTER, SHELLY W (EPDH)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:W
Last Name:HUNTER
Suffix:
Gender:F
Credentials:EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2679 EASTOVER TER
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6930
Mailing Address - Country:US
Mailing Address - Phone:541-601-5534
Mailing Address - Fax:
Practice Address - Street 1:2679 EASTOVER TER
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6930
Practice Address - Country:US
Practice Address - Phone:541-601-5534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2789124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR81-2384463OtherIRS EIN #