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General NPI Number Information
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NPI Number | 1194919779
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Entity Type | Individual
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Provider Name | TODD DAVID SHOCKLEY D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/28/2007
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Last Update Date | 08/28/2007
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Provider Practice Location Address
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Address Line | 260 S LAWRENCE BLVD SUITE 102
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City | KEYSTONE HEIGHTS
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State | FL
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Zip | 32656-9217
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Country | US
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Telephone | 352-473-0707
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Fax | 352-473-5187
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Provider Business Mailing Address
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Address Line | 260 S LAWRENCE BLVD SUITE 102
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City | KEYSTONE HEIGHTS
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State | FL
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Zip | 32656-9217
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Country | US
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Telephone | 352-473-0707
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Fax | 352-473-5187
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN15741
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License Number State | FL
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