Provider Demographics
NPI:1124163068
Name:SHELLERUD, GARY MICHAEL (DDS, PERIODONTIST)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:SHELLERUD
Suffix:
Gender:M
Credentials:DDS, PERIODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 E SILVER SPUR LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99217-9321
Mailing Address - Country:US
Mailing Address - Phone:509-467-2407
Mailing Address - Fax:
Practice Address - Street 1:508 W 6TH AVE STE 208
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2730
Practice Address - Country:US
Practice Address - Phone:509-838-4321
Practice Address - Fax:509-838-4618
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000056781223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics