Provider Demographics
NPI:1780003723
Name:SHELLY SELF DMD PLLC
Entity Type:Organization
Organization Name:SHELLY SELF DMD PLLC
Other - Org Name:POULSBO CHILDREN'S DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MCKINLEY
Authorized Official - Middle Name:T
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-464-0779
Mailing Address - Street 1:19365 7TH AVE NE
Mailing Address - Street 2:SUITE D 108
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7441
Mailing Address - Country:US
Mailing Address - Phone:360-779-7115
Mailing Address - Fax:360-779-3990
Practice Address - Street 1:19365 7TH AVE NE
Practice Address - Street 2:SUITE D 108
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7441
Practice Address - Country:US
Practice Address - Phone:360-779-7115
Practice Address - Fax:360-779-3990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE10256261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5003603Medicaid
WA1008098Medicaid