Provider Demographics
NPI:1780955542
Name:SHACKELFORD, LEE STEPHEN (DDS)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:STEPHEN
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27515 S. 4410 RD.
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301
Mailing Address - Country:US
Mailing Address - Phone:918-256-4800
Mailing Address - Fax:918-258-4586
Practice Address - Street 1:27515 S. 4410 RD.
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301
Practice Address - Country:US
Practice Address - Phone:918-256-4800
Practice Address - Fax:918-258-4586
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6569122300000X
MO20040328961223G0001X
CA356521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice