Provider Demographics
NPI:1992826804
Name:ROY S. SHELBURNE, DDS, LTD
Entity Type:Organization
Organization Name:ROY S. SHELBURNE, DDS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:SILAS
Authorized Official - Last Name:SHELBURNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-546-2042
Mailing Address - Street 1:153 E MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277-2643
Mailing Address - Country:US
Mailing Address - Phone:276-546-2042
Mailing Address - Fax:276-546-3029
Practice Address - Street 1:153 E MORGAN AVE
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-2643
Practice Address - Country:US
Practice Address - Phone:276-546-2042
Practice Address - Fax:276-546-3029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401-005798122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9177403Medicaid