Healthcare Provider Details

I. General information

NPI: 1558864140
Provider Name (Legal Business Name): AUSTIN JAMES SHACKELFORD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 BALTIMORE DR
WILKES BARRE PA
18702-7900
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-808-5626
  • Fax: 570-808-6352
Mailing address:
  • Phone: 570-808-5626
  • Fax: 570-808-6352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDS045082
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: