Provider Demographics
NPI:1427755651
Name:AYDELOTTE, SHIRLEY MONTHA (RDH)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MONTHA
Last Name:AYDELOTTE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:MONTHA
Other - Last Name:MARQUARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:BLDG H-3718 GRUBER RD
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-396-1571
Mailing Address - Fax:910-396-6202
Practice Address - Street 1:BLDG H-3718 GRUBER RD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-396-1571
Practice Address - Fax:910-396-6202
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9994124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist