Provider Demographics
NPI:1689826653
Name:WITHERS, SHELLY ANNE (BS, RDH, MS)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANNE
Last Name:WITHERS
Suffix:
Gender:F
Credentials:BS, RDH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11092 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1706
Mailing Address - Country:US
Mailing Address - Phone:909-558-4631
Mailing Address - Fax:909-558-0313
Practice Address - Street 1:11092 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1706
Practice Address - Country:US
Practice Address - Phone:909-558-4631
Practice Address - Fax:909-558-0313
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH 19010124Q00000X
ORH5578124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDH 19010OtherSTATE LICENSE