Provider Demographics
NPI:1487630992
Name:SHEPHERD, STEPHEN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROBERT
Last Name:SHEPHERD
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 1:12569 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2420
Mailing Address - Country:US
Mailing Address - Phone:714-544-2220
Mailing Address - Fax:714-544-2701
Practice Address - Street 1:12569 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2420
Practice Address - Country:US
Practice Address - Phone:714-544-2220
Practice Address - Fax:714-544-2701
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA317061223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics