MEDICARE: ROANOKE PEDIATRIC DENTISTRY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	0401413481	VA

General Provider Information

NPI Number	:	1255841433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROANOKE PEDIATRIC DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	6112 PETERS CREEK RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24019-4028
Country	:	US
Telephone Number	:	540-563-1660
Fax Number	:

Provider Business Practice Location Address
First Line	:	6112 PETERS CREEK RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24019-4028
Country	:	US
Telephone Number	:	540-563-1660
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. COREY JOE SHEPPARD
Credential	:	DDS
Telephone Number	:	540-563-1660

Provider Enumeration Date	:	10/02/2017
Last Update Date	:	10/02/2017

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