Healthcare Provider Details

I. General information

NPI: 1083888580
Provider Name (Legal Business Name): TRAVIS TRENT SHEPHERD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 01/28/2022
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CENTER STREET WEST STE. A
KIMBERLY ID
83341
US

IV. Provider business mailing address

610 GARNET DR
KIMBERLY ID
83341-1942
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-5001
  • Fax: 208-423-4867
Mailing address:
  • Phone: 505-787-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3277
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: