MEDICARE: SHELHOUSE COMPREHENSIVE DENTAL LLC

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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1234	OTHER		DENTAL OFFICE

General Provider Information

NPI Number	:	1316288103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHELHOUSE COMPREHENSIVE DENTAL LLC

Provider Business Mailing Address
First Line	:	5335 FAR HILLS AVE STE 210
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-2317
Country	:	US
Telephone Number	:	937-439-0275
Fax Number	:	937-439-0276

Provider Business Practice Location Address
First Line	:	5335 FAR HILLS AVE STE 210
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-2317
Country	:	US
Telephone Number	:	937-439-0275
Fax Number	:	937-439-0276

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	PAM A BROWN
Credential	:
Telephone Number	:	937-439-0275

Provider Enumeration Date	:	03/05/2013
Last Update Date	:	03/05/2013

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