Provider Demographics
NPI:1316076292
Name:SHEFTALL,JR., STANLEY W (DMD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:W
Last Name:SHEFTALL,JR.
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 1:272 KELLER RD
Mailing Address - Street 2:
Mailing Address - City:HARTWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30643-4270
Mailing Address - Country:US
Mailing Address - Phone:706-371-4052
Mailing Address - Fax:
Practice Address - Street 1:3620 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-7334
Practice Address - Country:US
Practice Address - Phone:864-261-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC28911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX2891Medicaid