Provider Demographics
NPI:1427151059
Name:ANGELA R SHELTON DMD PSC
Entity type:Organization
Organization Name:ANGELA R SHELTON DMD PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-352-5566
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40159-0778
Mailing Address - Country:US
Mailing Address - Phone:270-352-5566
Mailing Address - Fax:270-352-5602
Practice Address - Street 1:299 WEST LINCOLN TRAIL BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160
Practice Address - Country:US
Practice Address - Phone:270-352-5566
Practice Address - Fax:270-352-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY551702OtherUNITED CONCORDIA TRICARE
KY6000338Medicaid