Healthcare Provider Details

I. General information

NPI: 1306299854
Provider Name (Legal Business Name): WESLEY J SHELNUTT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 BALD RIDGE MARINA RD SUITE 200
CUMMING GA
30041-8526
US

IV. Provider business mailing address

1200 BALD RIDGE MARINA RD SUITE 200
CUMMING GA
30041-8526
US

V. Phone/Fax

Practice location:
  • Phone: 770-781-8650
  • Fax: 770-781-8650
Mailing address:
  • Phone: 770-781-8650
  • Fax: 770-781-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015174
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: