Provider Demographics
NPI:1154330082
Name:SHULL, COLLEEN C (DMD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:C
Last Name:SHULL
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 1:35 SPESUTIE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN PROVING GROUND
Mailing Address - State:MD
Mailing Address - Zip Code:21005-1413
Mailing Address - Country:US
Mailing Address - Phone:703-622-4608
Mailing Address - Fax:
Practice Address - Street 1:2501 OAKINGTON ST
Practice Address - Street 2:APG DENTAL CLINIC
Practice Address - City:APG
Practice Address - State:MD
Practice Address - Zip Code:21005
Practice Address - Country:US
Practice Address - Phone:410-278-1795
Practice Address - Fax:410-278-1792
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026397L1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics