Provider Demographics
NPI:1073275376
Name:SHEPPARD DENTAL GROUP LLC
Entity Type:Organization
Organization Name:SHEPPARD DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-786-2104
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:MI
Mailing Address - Zip Code:49756-0209
Mailing Address - Country:US
Mailing Address - Phone:989-786-2104
Mailing Address - Fax:
Practice Address - Street 1:3051 BAY ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:MI
Practice Address - Zip Code:49756-8855
Practice Address - Country:US
Practice Address - Phone:734-250-1301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-13
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental