Healthcare Provider Details

I. General information

NPI: 1861485815
Provider Name (Legal Business Name): SHELLEY NELSON WAKEFIELD D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14682 PENNOCK AVE
APPLE VALLEY MN
55124-7429
US

IV. Provider business mailing address

1601 HIGHPOINT CURV
BURNSVILLE MN
55337-3933
US

V. Phone/Fax

Practice location:
  • Phone: 952-431-5774
  • Fax:
Mailing address:
  • Phone: 952-891-4918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9428
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: