Provider Demographics
NPI:1386855880
Name:SHEPARD, KEITH E (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:E
Last Name:SHEPARD
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 1:705 WINDY HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-1854
Mailing Address - Country:US
Mailing Address - Phone:770-801-1641
Mailing Address - Fax:770-801-0587
Practice Address - Street 1:705 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-1854
Practice Address - Country:US
Practice Address - Phone:770-801-1641
Practice Address - Fax:770-801-0587
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122728BMedicaid