Healthcare Provider Details

I. General information

NPI: 1245492933
Provider Name (Legal Business Name): RYAN S SHEPHERD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 PROSPECT PL NE SUITE D
ALBUQUERQUE NM
87110-4309
US

IV. Provider business mailing address

6123 PURPLE ASTER LN NE
ALBUQUERQUE NM
87111-8082
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-4484
  • Fax:
Mailing address:
  • Phone: 505-544-1043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2998
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: