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General NPI Number Information
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NPI Number | 1558378208
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Entity Type | Organization
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Legal Business Name | SHELBY DENTAL ARTS, INC.
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Dates
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Enumeration Date | 08/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 70 W SMILEY AVE
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City | SHELBY
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State | OH
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Zip | 44875-1056
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Country | US
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Telephone | 419-342-4566
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Fax | 419-347-6617
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Provider Business Mailing Address
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Address Line | 70 WEST SMILEY AVE. P.O.BOX 210
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City | SHELBY
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State | OH
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Zip | 44875-1326
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Country | US
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Telephone | 419-342-4566
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Fax | 419-347-6617
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY EDWARD JOHNSON
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Credential | DDS
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Telephone | 419-342-4566
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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 | 15765
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License Number State | OH
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