Provider Demographics
NPI:1063836922
Name:SHEPPARD, JOHN EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWIN
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8548
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-8548
Mailing Address - Country:US
Mailing Address - Phone:856-589-8012
Mailing Address - Fax:856-589-8013
Practice Address - Street 1:438 GANTTOWN RD
Practice Address - Street 2:STE A6
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2341
Practice Address - Country:US
Practice Address - Phone:856-589-8012
Practice Address - Fax:856-589-8013
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01177300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist