Provider Demographics
NPI:1265164578
Name:ROSE, SHELBY JENAE (DDS)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:JENAE
Last Name:ROSE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:JENAE
Other - Last Name:BLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:7149 NW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-1687
Mailing Address - Country:US
Mailing Address - Phone:402-335-7594
Mailing Address - Fax:
Practice Address - Street 1:5640 SOUTH ST STE 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2231
Practice Address - Country:US
Practice Address - Phone:402-489-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE78411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice