Healthcare Provider Details

I. General information

NPI: 1720593015
Provider Name (Legal Business Name): SHELLY PETERS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 KENNEDY DR
RANGELY CO
81648-3502
US

IV. Provider business mailing address

905 COUNTY ROAD 101
RANGELY CO
81648-2034
US

V. Phone/Fax

Practice location:
  • Phone: 970-675-3245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number000903508
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: