Provider Demographics
NPI:1457572455
Name:SHACKELTON, EMILY ANNE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ANNE
Last Name:SHACKELTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 35TH AVE NE
Mailing Address - Street 2:#4
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115
Mailing Address - Country:US
Mailing Address - Phone:206-525-9110
Mailing Address - Fax:206-525-0955
Practice Address - Street 1:6850 35TH AVE NE
Practice Address - Street 2:#4
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115
Practice Address - Country:US
Practice Address - Phone:206-525-9110
Practice Address - Fax:206-525-0955
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE8244122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5051818Medicaid