Healthcare Provider Details

I. General information

NPI: 1417030495
Provider Name (Legal Business Name): MONETTE MARIE SHUUTLEWORTH DDS/PERIODONTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 WISCONSIN AVE NW SUITE #511
WASHINGTON DC
20015
US

IV. Provider business mailing address

25 RICH BRANCH CT
GAITHERSBURG MD
20878
US

V. Phone/Fax

Practice location:
  • Phone: 202-966-0620
  • Fax: 240-314-7199
Mailing address:
  • Phone: 240-314-0550
  • Fax: 240-314-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10006
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5207
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: