Provider Demographics
NPI:1124237805
Name:MIMS, SHELTON PARK (DMD)
Entity type:Individual
Prefix:DR
First Name:SHELTON
Middle Name:PARK
Last Name:MIMS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:SHELTON
Other - Middle Name:PARK
Other - Last Name:MIMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4101 BALMORAL DR SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6409
Mailing Address - Country:US
Mailing Address - Phone:256-880-6556
Mailing Address - Fax:256-880-2945
Practice Address - Street 1:4101 BALMORAL DR SW
Practice Address - Street 2:SUITE B
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6409
Practice Address - Country:US
Practice Address - Phone:256-880-6556
Practice Address - Fax:256-880-2945
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL38791223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics