Provider Demographics
NPI:1770637860
Name:POWELL DENTAL GROUP-SHELLEY D SHULTS DDS LLC
Entity Type:Organization
Organization Name:POWELL DENTAL GROUP-SHELLEY D SHULTS DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHULTS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, DDS
Authorized Official - Phone:614-436-4433
Mailing Address - Street 1:39 CLAIREDAN DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8064
Mailing Address - Country:US
Mailing Address - Phone:614-436-4433
Mailing Address - Fax:614-436-6055
Practice Address - Street 1:39 CLAIREDAN DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-8064
Practice Address - Country:US
Practice Address - Phone:614-436-4433
Practice Address - Fax:614-436-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7392470001Medicare NSC