Provider Demographics
NPI:1497598528
Name:SHELLEY, MARK MCLEOD (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:MCLEOD
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 ASHEFORD GREEN AVE NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8109
Mailing Address - Country:US
Mailing Address - Phone:704-699-8316
Mailing Address - Fax:
Practice Address - Street 1:8831 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:704-271-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC139181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty