MEDICARE: DR. ROGER DARON SHELINE DDS

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	12009625A	IN

General Provider Information

NPI Number	:	1740386184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER DARON SHELINE DDS

Provider Business Mailing Address
First Line	:	232 WATERFALL DR
Second Line	:
City	:	ELKHART
State	:	IN
Zip	:	46516-3668
Country	:	US
Telephone Number	:	574-293-8744
Fax Number	:	574-293-3709

Provider Business Practice Location Address
First Line	:	232 WATERFALL DR
Second Line	:
City	:	ELKHART
State	:	IN
Zip	:	46516-3668
Country	:	US
Telephone Number	:	574-293-8744
Fax Number	:	574-293-3709

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

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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