Provider Demographics
NPI:1871889782
Name:SHELTON, JARED MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:MICHAEL
Last Name:SHELTON
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 1:3780 LADY DI LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-1020
Mailing Address - Country:US
Mailing Address - Phone:270-839-5414
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:D508 COLLEGE OF DENTISTRY DIVISION OF ORAL SURGERY
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0292
Practice Address - Country:US
Practice Address - Phone:859-323-6101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9055122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist