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General NPI Number Information
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NPI Number | 1104372556
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Entity Type | Organization
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Legal Business Name | GARY M SHELLERUD DDS
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Dates
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Enumeration Date | 08/26/2016
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Last Update Date | 08/26/2016
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Provider Practice Location Address
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Address Line | 508 W 6TH AVE STE 208
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City | SPOKANE
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State | WA
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Zip | 99204-2730
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Country | US
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Telephone | 509-838-4321
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Fax | 509-838-4618
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Provider Business Mailing Address
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Address Line | 508 W 6TH AVE STE 208
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City | SPOKANE
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State | WA
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Zip | 99204-2730
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Country | US
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Telephone | 509-838-4321
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Fax | 509-838-4618
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Authorized Official
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Title or Position | OWNER
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Name | DR. GARY M SHELLERUD
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Credential | DDS
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Telephone | 509-838-4321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 5678
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License Number State | WA
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