Provider Demographics
NPI:1922090869
Name:THE DENTAL VILLAGE OF SHELTON
Entity Type:Organization
Organization Name:THE DENTAL VILLAGE OF SHELTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:OLIVIA
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-432-1978
Mailing Address - Street 1:301 E WALLACE KNEELAND BLVD
Mailing Address - Street 2:STE 224
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2985
Mailing Address - Country:US
Mailing Address - Phone:360-432-1978
Mailing Address - Fax:360-432-2377
Practice Address - Street 1:2129 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-1927
Practice Address - Country:US
Practice Address - Phone:360-432-1978
Practice Address - Fax:360-432-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE79221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty