MEDICARE: SYDNEY JAYMES SHEPARD DMD

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	1223G0001X	General Practice Dentistry	DN29140	FL

General Provider Information

NPI Number	:	1558105791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY JAYMES SHEPARD DMD

Provider Business Mailing Address
First Line	:	72 INDIAN BAYOU DR
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-4447
Country	:	US
Telephone Number	:	850-797-2902
Fax Number	:

Provider Business Practice Location Address
First Line	:	12276 SAN JOSE BLVD STE 313
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-8632
Country	:	US
Telephone Number	:	904-807-8744
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2024
Last Update Date	:	04/07/2026

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