=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760046254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHEPPARD DENTAL HEALTH AND ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3096 W M 32
-----------------------------------------------------
City | GAYLORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49735-9753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-732-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3096 W M 32
-----------------------------------------------------
City | GAYLORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49735-9753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-732-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | REBEKAH KATHRYN SHEPPARD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 989-732-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------