=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043395189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR B ENJAMIN SHELTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 05/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 E 33RD STREET
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-243-3714
-----------------------------------------------------
Fax | 410-338-0977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 E 33RD ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-243-3714
-----------------------------------------------------
Fax | 410-338-0977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. BENJAMIN FRANKLIN SHELTON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 410-243-3714
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5289
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------