MEDICARE: DR. JERRY DAVID SHEPHERD II DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3418	WV
2	1223G0001X	General Practice Dentistry	10022	SC

General Provider Information

NPI Number	:	1508831371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY DAVID SHEPHERD II DDS

Provider Business Mailing Address
First Line	:	1663 GLENNS BAY RD
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-4836
Country	:	US
Telephone Number	:	843-215-6080
Fax Number	:

Provider Business Practice Location Address
First Line	:	1663 GLENNS BAY RD
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-4836
Country	:	US
Telephone Number	:	843-215-6080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	04/27/2023

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