Provider Demographics
NPI:1104933571
Name:SHELBY, DIANA SUE (DPD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:SUE
Last Name:SHELBY
Suffix:
Gender:F
Credentials:DPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 WEST CLEARWATER AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-374-1660
Mailing Address - Fax:509-374-9374
Practice Address - Street 1:5219 WEST CLEARWATER AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-374-1660
Practice Address - Fax:509-374-9374
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000253122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA15049275Medicaid