1336280957 NPI number — DR. SHELLY SELF DMD

Table of content: DR. SHELLY SELF DMD (NPI 1336280957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336280957 NPI number — DR. SHELLY SELF DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELF
Provider First Name:
SHELLY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIN
Provider Other First Name:
SHELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336280957
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9902 NE MONSAAS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAINBRIDGE ISLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98110-1103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-464-0990
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19365 7TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE D108
Provider Business Practice Location Address City Name:
POULSBO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98370-7441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-779-7115
Provider Business Practice Location Address Fax Number:
360-779-3990
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DE00010256 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: DE10256 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2035573 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1008098 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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