Healthcare Provider Details

I. General information

NPI: 1790944098
Provider Name (Legal Business Name): MELISSA DANETTE SHOTELL DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13955 MONO WAY SUITE B
SONORA CA
95370-2832
US

IV. Provider business mailing address

PO BOX 217
SOULSBYVILLE CA
95372-0217
US

V. Phone/Fax

Practice location:
  • Phone: 209-532-2288
  • Fax: 614-436-2299
Mailing address:
  • Phone: 209-536-1954
  • Fax: 614-436-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number58232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: