Provider Demographics
NPI:1922257021
Name:SHELLEY, CLINT TYLER (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:TYLER
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4861 LOGISTICS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-9060
Mailing Address - Fax:
Practice Address - Street 1:4861 LOGISTICS AVE
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7066379-99211223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice