MEDICARE: TOM SHELLY D.D.S., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	5796	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215006879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOM SHELLY D.D.S., M.S.

Provider Business Mailing Address
First Line	:	902 2ND AVE N
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-3958
Country	:	US
Telephone Number	:	515-573-8351
Fax Number	:	515-576-3513

Provider Business Practice Location Address
First Line	:	902 2ND AVE N
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-3958
Country	:	US
Telephone Number	:	515-573-8351
Fax Number	:	515-573-3513

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	07/09/2007

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