Provider Demographics
NPI:1306874797
Name:WILSON, SHELLEY ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2520 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1935
Mailing Address - Country:US
Mailing Address - Phone:269-983-7683
Mailing Address - Fax:269-983-5663
Practice Address - Street 1:2460 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1874
Practice Address - Country:US
Practice Address - Phone:269-983-5583
Practice Address - Fax:269-983-5663
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010176561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics