Provider Demographics
NPI:1760637714
Name:SHELTON-THOMPSON-VON SICK, PLC
Entity Type:Organization
Organization Name:SHELTON-THOMPSON-VON SICK, PLC
Other - Org Name:DR.'S SHELTON,THOMPSON, & VONSICK, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SEC/TRES
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-847-5360
Mailing Address - Street 1:5636 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3875
Mailing Address - Country:US
Mailing Address - Phone:727-847-5360
Mailing Address - Fax:727-842-2474
Practice Address - Street 1:5636 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-3875
Practice Address - Country:US
Practice Address - Phone:727-847-5360
Practice Address - Fax:727-842-2474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 73361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6397180001Medicare NSC