Provider Demographics
NPI:1215951835
Name:LYLE, SHELLEY ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:ANN
Last Name:LYLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 KEENE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6639
Mailing Address - Country:US
Mailing Address - Phone:573-442-1869
Mailing Address - Fax:573-442-4165
Practice Address - Street 1:3111 KEENE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6639
Practice Address - Country:US
Practice Address - Phone:573-442-1869
Practice Address - Fax:573-442-4165
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0141311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice