Provider Demographics
NPI:1760541445
Name:SHELLY, NICOLAS MIHAILOFF (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:MIHAILOFF
Last Name:SHELLY
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 1:110 NORTH NAPPANEE STREET
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514
Mailing Address - Country:US
Mailing Address - Phone:574-293-5216
Mailing Address - Fax:
Practice Address - Street 1:110 NORTH NAPPANEE STREET
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514
Practice Address - Country:US
Practice Address - Phone:574-293-5216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006758A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice