Provider Demographics
NPI:1740386184
Name:SHELINE, ROGER DARON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DARON
Last Name:SHELINE
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 1:232 WATERFALL DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-3668
Mailing Address - Country:US
Mailing Address - Phone:574-293-8744
Mailing Address - Fax:574-293-3709
Practice Address - Street 1:232 WATERFALL DR
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3668
Practice Address - Country:US
Practice Address - Phone:574-293-8744
Practice Address - Fax:574-293-3709
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009625A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice