Provider Demographics
NPI:1760530661
Name:SHELTON, MISTY L
Entity Type:Individual
Prefix:DR
First Name:MISTY
Middle Name:L
Last Name:SHELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E SUNSHINE ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1214
Mailing Address - Country:US
Mailing Address - Phone:417-881-3220
Mailing Address - Fax:417-881-6473
Practice Address - Street 1:1500 E SUNSHINE ST
Practice Address - Street 2:SUITE H
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1214
Practice Address - Country:US
Practice Address - Phone:417-881-3220
Practice Address - Fax:417-881-6473
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0159491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOBZ5709386OtherMO. DEPT. OF HEALTH
MO015949OtherDENTAL LICENSE