Provider Demographics
NPI:1760646509
Name:MCDONALD, SHELLEY WILKERSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:WILKERSON
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3107
Mailing Address - Country:US
Mailing Address - Phone:601-482-8986
Mailing Address - Fax:601-482-6100
Practice Address - Street 1:1922 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3107
Practice Address - Country:US
Practice Address - Phone:601-482-8986
Practice Address - Fax:601-482-6100
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3468-08390200000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program