=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629315643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN DAVID SHEPHERD D.M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2013
-----------------------------------------------------
Last Update Date | 01/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2006 OLD MONTGOMERY HWY
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35244-1658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-987-4055
-----------------------------------------------------
Fax | 205-987-4635
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2006 OLD MONTGOMERY HWY
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35244-1658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-987-4055
-----------------------------------------------------
Fax | 205-987-4635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE COORDINATOR
-----------------------------------------------------
Name | MRS. CINDY R. BRASWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-987-4055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3970
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------