Provider Demographics
NPI:1912665241
Name:SHELLEY, JACOB CARL (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CARL
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N CANYON ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5817
Mailing Address - Country:US
Mailing Address - Phone:575-654-2107
Mailing Address - Fax:
Practice Address - Street 1:701 N CANYON ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5817
Practice Address - Country:US
Practice Address - Phone:575-654-2107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD55341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics