Provider Demographics
NPI:1396158986
Name:SHELESTAK, MICHAEL RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:SHELESTAK
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:PO BOX 636896
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6896
Mailing Address - Country:US
Mailing Address - Phone:330-884-7158
Mailing Address - Fax:330-884-7175
Practice Address - Street 1:3115 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST MIDDLESEX
Practice Address - State:PA
Practice Address - Zip Code:16159-3411
Practice Address - Country:US
Practice Address - Phone:724-528-1515
Practice Address - Fax:724-528-0217
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040096122300000X
PAFS47014281223G0001X
390200000X
OH300245811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program