MEDICARE: DR. JAMES GERARD SHORTELL D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12746	MO

General Provider Information

NPI Number	:	1760568653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES GERARD SHORTELL D.D.S.

Provider Business Mailing Address
First Line	:	1608 S BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2208
Country	:	US
Telephone Number	:	314-781-7352
Fax Number	:

Provider Business Practice Location Address
First Line	:	1608 S BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2208
Country	:	US
Telephone Number	:	314-781-7352
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/08/2007

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