Healthcare Provider Details

I. General information

NPI: 1871889782
Provider Name (Legal Business Name): JARED MICHAEL SHELTON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST D508 COLLEGE OF DENTISTRY DIVISION OF ORAL SURGERY
LEXINGTON KY
40536-0292
US

IV. Provider business mailing address

3780 LADY DI LN
LEXINGTON KY
40517-1020
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6101
  • Fax:
Mailing address:
  • Phone: 270-839-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9055
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9055
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: