=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871963843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELISSA D SHOTELL DMD MS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2015
-----------------------------------------------------
Last Update Date | 10/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14570 MONO WAY STE I
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370-8997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-536-1954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 217
-----------------------------------------------------
City | SOULSBYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95372-0217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-536-1954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MELISSA D SHOTELL
-----------------------------------------------------
Credential | DMD MS
-----------------------------------------------------
Telephone | 209-536-1954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58232
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 58232
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------