Provider Demographics
NPI:1558864140
Name:SHACKELFORD, AUSTIN JAMES (DMD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JAMES
Last Name:SHACKELFORD
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-808-5626
Mailing Address - Fax:570-808-6352
Practice Address - Street 1:675 BALTIMORE DR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7900
Practice Address - Country:US
Practice Address - Phone:570-808-5626
Practice Address - Fax:570-808-6352
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0450821223P0106X
390200000X
AZ10177122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program