Provider Demographics
NPI:1366604449
Name:GALLEGOS, SHELLY MARIE (DDS)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7878 GATEWAY BLVD E STE 101
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-1802
Mailing Address - Country:US
Mailing Address - Phone:915-595-3333
Mailing Address - Fax:
Practice Address - Street 1:7878 GATEWAY BLVD E STE 101
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1802
Practice Address - Country:US
Practice Address - Phone:915-595-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD 34 04122300000X
TX26071122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist