Provider Demographics
NPI:1104484203
Name:SHELTON, ETHAN JOHN HOWARD (DMD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOHN HOWARD
Last Name:SHELTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 30TH AVE N APT 304
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1395
Mailing Address - Country:US
Mailing Address - Phone:618-638-3868
Mailing Address - Fax:
Practice Address - Street 1:2018 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7108
Practice Address - Country:US
Practice Address - Phone:270-443-9099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN110601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice