Provider Demographics
NPI:1497164008
Name:SHEPPARD, KEITH L (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:L
Last Name:SHEPPARD
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 1:11300 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-9026
Mailing Address - Country:US
Mailing Address - Phone:530-432-1543
Mailing Address - Fax:
Practice Address - Street 1:11300 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946-9026
Practice Address - Country:US
Practice Address - Phone:530-432-1543
Practice Address - Fax:530-432-1543
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA638271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice