Provider Demographics
NPI:1306093133
Name:SHELBY, DANIEL J (DMD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:SHELBY
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 1:400 E WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4079
Mailing Address - Country:US
Mailing Address - Phone:423-926-4867
Mailing Address - Fax:
Practice Address - Street 1:400 E WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-926-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2328122300000X
TN106881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist