Basic Information
| Provider Information | |||||||||
| NPI: | 1780955542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHACKELFORD | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27515 S. 4410 RD. | ||||||||
| Address2: | |||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182564800 | ||||||||
| FaxNumber: | 9182584586 | ||||||||
| Practice Location | |||||||||
| Address1: | 27515 S. 4410 RD. | ||||||||
| Address2: | |||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182564800 | ||||||||
| FaxNumber: | 9182584586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2012 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 6569 | OK | Y | Dental Providers | Dentist | 1223G0001X | 2004032896 | MO | N | Dental Providers | Dentist | General Practice | 1223G0001X | 35652 | CA | N | Dental Providers | Dentist | General Practice |
No ID Information.