Provider Demographics
NPI:1194919779
Name:SHOCKLEY, TODD DAVID (DMD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:DAVID
Last Name:SHOCKLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S LAWRENCE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-9217
Mailing Address - Country:US
Mailing Address - Phone:352-473-0707
Mailing Address - Fax:352-473-5187
Practice Address - Street 1:260 S LAWRENCE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9217
Practice Address - Country:US
Practice Address - Phone:352-473-0707
Practice Address - Fax:352-473-5187
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN157411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice