Provider Demographics
NPI:1124266804
Name:SULLENS, SHELLY REA (DMD)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:REA
Last Name:SULLENS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 SW UMATILLA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7039
Mailing Address - Country:US
Mailing Address - Phone:541-504-3900
Mailing Address - Fax:541-504-3907
Practice Address - Street 1:121 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-8718
Practice Address - Country:US
Practice Address - Phone:888-468-0022
Practice Address - Fax:541-504-3907
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6207122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist