Healthcare Provider Details

I. General information

NPI: 1831351774
Provider Name (Legal Business Name): SPENCER GRISSOM SHELLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25485 LANKFORD HIGHWAY
ONLEY VA
23418
US

IV. Provider business mailing address

PO BOX 599
ONLEY VA
23418-0599
US

V. Phone/Fax

Practice location:
  • Phone: 757-787-7000
  • Fax:
Mailing address:
  • Phone: 757-787-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401412147
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: