Healthcare Provider Details

I. General information

NPI: 1124018619
Provider Name (Legal Business Name): CRAIG JAMES SHEPHERD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 BLUE HERON DR
WEXFORD PA
15090-2514
US

IV. Provider business mailing address

156 BLUE HERON DR
WEXFORD PA
15090-2514
US

V. Phone/Fax

Practice location:
  • Phone: 724-759-7948
  • Fax: 724-759-7952
Mailing address:
  • Phone: 724-759-7948
  • Fax: 724-759-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberDS031543L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: