MEDICARE: SAVANNAH LEIGH SHETTERLY DMD

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	390200000X	Student in an Organized Health Care Education/Training Program		AZ

General Provider Information

NPI Number	:	1225961030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAVANNAH LEIGH SHETTERLY DMD

Provider Business Mailing Address
First Line	:	8644 W FULLAM ST
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-3035
Country	:	US
Telephone Number	:	623-298-8808
Fax Number	:

Provider Business Practice Location Address
First Line	:	21001 N TATUM BLVD STE 80-1690
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-5233
Country	:	US
Telephone Number	:	480-419-9200
Fax Number	:

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

Provider Enumeration Date	:	06/03/2026
Last Update Date	:	06/03/2026

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