Healthcare Provider Details

I. General information

NPI: 1922708247
Provider Name (Legal Business Name): SHELBY DENISE MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12427 HIGHWAY 231
YOUNGSTOWN FL
32466-2562
US

IV. Provider business mailing address

12427 HIGHWAY 231
YOUNGSTOWN FL
32466-2562
US

V. Phone/Fax

Practice location:
  • Phone: 850-753-3246
  • Fax:
Mailing address:
  • Phone: 860-539-0681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN30962
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: