Provider Demographics
NPI:1942290226
Name:SHOCKLEY, LEO RUSSELL JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:RUSSELL
Last Name:SHOCKLEY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8991 W SHIPLEY RD
Mailing Address - Street 2:
Mailing Address - City:ALBORN
Mailing Address - State:MN
Mailing Address - Zip Code:55702-8277
Mailing Address - Country:US
Mailing Address - Phone:210-393-5115
Mailing Address - Fax:
Practice Address - Street 1:601 HIGHWAY 73
Practice Address - Street 2:
Practice Address - City:FLOODWOOD
Practice Address - State:MN
Practice Address - Zip Code:55736-8450
Practice Address - Country:US
Practice Address - Phone:218-476-2969
Practice Address - Fax:218-476-1599
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN92311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice