Healthcare Provider Details

I. General information

NPI: 1104372556
Provider Name (Legal Business Name): GARY M SHELLERUD DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 W 6TH AVE STE 208
SPOKANE WA
99204-2730
US

IV. Provider business mailing address

508 W 6TH AVE STE 208
SPOKANE WA
99204-2730
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-4321
  • Fax: 509-838-4618
Mailing address:
  • Phone: 509-838-4321
  • Fax: 509-838-4618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5678
License Number StateWA

VIII. Authorized Official

Name: DR. GARY M SHELLERUD
Title or Position: OWNER
Credential: DDS
Phone: 509-838-4321