Basic Information
| Provider Information | |||||||||
| NPI: | 1003966714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELDON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S., M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 3485 W 10TH ST STE C | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806345368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703534746 | ||||||||
| FaxNumber: | 9703534751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 06/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 9284 | CO | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
ID Information
| ID | Type | State | Issuer | Description | DEN.00009284 | 01 | CO | CO DENTAL LICENSE | OTHER | 54556775 | 05 | CO | MEDICAID |