Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | DS026397L | PA |
NPI | 1154330082 |
---|---|
Provider Name | Dr. Colleen C. Shull |
First Address | Aberdeen Proving Ground, MD 21005-1413 |
Second Address | Apg, MD 21005 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2006 |
Last Update Date | 08/07/2007 |