Provider Demographics
NPI:1386845949
Name:SHEPARD, LINDA DIANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:DIANE
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 JOHN BOSWELL RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972-5163
Mailing Address - Country:US
Mailing Address - Phone:518-643-9719
Mailing Address - Fax:
Practice Address - Street 1:326 TOM MILLER RD
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6430
Practice Address - Country:US
Practice Address - Phone:518-563-7097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYD-0431331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice