Provider Demographics
NPI:1477522092
Name:SHIPLOV, JEREMIAH JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:JOSEPH
Last Name:SHIPLOV
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 1:231 OCKLEY DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3024
Mailing Address - Country:US
Mailing Address - Phone:318-869-4102
Mailing Address - Fax:318-456-6776
Practice Address - Street 1:1067 TWINING DR
Practice Address - Street 2:
Practice Address - City:BERKSDALE AFB
Practice Address - State:LA
Practice Address - Zip Code:71110-2414
Practice Address - Country:US
Practice Address - Phone:318-456-6776
Practice Address - Fax:318-456-6636
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA21648OtherSTATE DRUG DEPT OF HEALTH
LA21648OtherSTATE DRUG DEPT OF HEALTH