Healthcare Provider Details

I. General information

NPI: 1124163068
Provider Name (Legal Business Name): GARY MICHAEL SHELLERUD DDS, PERIODONTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
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

4309 E SILVER SPUR LN
SPOKANE WA
99217-9321
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-4321
  • Fax: 509-838-4618
Mailing address:
  • Phone: 509-467-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number00005678
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: