Provider Demographics
NPI:1487744397
Name:BURLISON, SHELTON KEITH (DMD)
Entity type:Individual
Prefix:DR
First Name:SHELTON
Middle Name:KEITH
Last Name:BURLISON
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 1:2730 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8626
Mailing Address - Country:US
Mailing Address - Phone:678-473-4756
Mailing Address - Fax:678-473-7691
Practice Address - Street 1:2730 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8626
Practice Address - Country:US
Practice Address - Phone:678-473-4756
Practice Address - Fax:678-473-7691
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0114081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice