Healthcare Provider Details

I. General information

NPI: 1871963843
Provider Name (Legal Business Name): MELISSA D SHOTELL DMD MS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14570 MONO WAY STE I
SONORA CA
95370-8997
US

IV. Provider business mailing address

PO BOX 217
SOULSBYVILLE CA
95372-0217
US

V. Phone/Fax

Practice location:
  • Phone: 209-536-1954
  • Fax:
Mailing address:
  • Phone: 209-536-1954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number58232
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number58232
License Number StateCA

VIII. Authorized Official

Name: DR. MELISSA D SHOTELL
Title or Position: PRESIDENT
Credential: DMD MS
Phone: 209-536-1954