Healthcare Provider Details

I. General information

NPI: 1316044993
Provider Name (Legal Business Name): CLARENCE E SHELTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W 97TH ST SUITE 1D
NEW YORK NY
10025-6053
US

IV. Provider business mailing address

327 BEECHMONT DR
NEW ROCHELLE NY
10804-4601
US

V. Phone/Fax

Practice location:
  • Phone: 212-932-2203
  • Fax: 212-932-0996
Mailing address:
  • Phone: 914-633-8995
  • Fax: 212-932-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number28396
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: