Provider Demographics
NPI:1740305549
Name:RAICHART, SHELLY SUZANNE (DDS)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:SUZANNE
Last Name:RAICHART
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:PO BOX 1478
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-1478
Mailing Address - Country:US
Mailing Address - Phone:970-926-1519
Mailing Address - Fax:970-926-1044
Practice Address - Street 1:0057 EDWARDS ACCESS RD
Practice Address - Street 2:SUITE 21
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-926-1519
Practice Address - Fax:970-926-1044
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO72091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice