=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407548720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERINA SHEPARD DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2023
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5693 CORAL RIDGE DR
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33076-3160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-757-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3168 NW 123RD AVE
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33323-3020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-777-9815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 27918
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------