=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245687060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIN A SHIVELER, DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2016
-----------------------------------------------------
Last Update Date | 05/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2027 THOMASVILLE RD STE 101
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-0752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-385-0231
-----------------------------------------------------
Fax | 850-385-9230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2027 THOMASVILLE RD STE 101
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32308-0752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-385-0231
-----------------------------------------------------
Fax | 850-385-9230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. ERIN SHIVELER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 850-321-4964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN19010
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------