Provider Demographics
NPI:1750422713
Name:SHELTON, STACEY ELIZABETH (DMD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ELIZABETH
Last Name:SHELTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:BETH
Other - Middle Name:ABEL
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:415 N GLOSTER ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-3625
Mailing Address - Country:US
Mailing Address - Phone:662-842-2055
Mailing Address - Fax:662-680-4787
Practice Address - Street 1:415 N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3625
Practice Address - Country:US
Practice Address - Phone:662-842-2055
Practice Address - Fax:662-680-4787
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3103-991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice