Provider Demographics
NPI:1083888580
Name:SHEPHERD, TRAVIS TRENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:TRENT
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 GARNET DR
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-1942
Mailing Address - Country:US
Mailing Address - Phone:505-787-0082
Mailing Address - Fax:
Practice Address - Street 1:901 CENTER STREET WEST STE. A
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341
Practice Address - Country:US
Practice Address - Phone:208-423-5001
Practice Address - Fax:208-423-4867
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM32771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice