Provider Demographics
NPI:1861485815
Name:WAKEFIELD, SHELLEY NELSON (DDS)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:NELSON
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 HIGHPOINT CURV
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-3933
Mailing Address - Country:US
Mailing Address - Phone:952-891-4918
Mailing Address - Fax:
Practice Address - Street 1:14682 PENNOCK AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7429
Practice Address - Country:US
Practice Address - Phone:952-431-5774
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN94281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice