Provider Demographics
NPI:1790944098
Name:SHOTELL, MELISSA DANETTE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:DANETTE
Last Name:SHOTELL
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:SOULSBYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95372-0217
Mailing Address - Country:US
Mailing Address - Phone:209-536-1954
Mailing Address - Fax:614-436-2299
Practice Address - Street 1:13955 MONO WAY
Practice Address - Street 2:SUITE B
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-2832
Practice Address - Country:US
Practice Address - Phone:209-532-2288
Practice Address - Fax:614-436-2299
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA582321223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program