Provider Demographics
NPI:1679051809
Name:SHELTON, BROOKE ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:SHELTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S DIXIE BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-1105
Mailing Address - Country:US
Mailing Address - Phone:270-351-5858
Mailing Address - Fax:270-351-6079
Practice Address - Street 1:1100 S DIXIE BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-1105
Practice Address - Country:US
Practice Address - Phone:270-351-5858
Practice Address - Fax:270-351-6079
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY10172OtherDENTAL LICENSE