Provider Demographics
NPI:1508831371
Name:SHEPHERD, JERRY DAVID II (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DAVID
Last Name:SHEPHERD
Suffix:II
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 1:1663 GLENNS BAY RD
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-4836
Mailing Address - Country:US
Mailing Address - Phone:843-215-6080
Mailing Address - Fax:
Practice Address - Street 1:1663 GLENNS BAY RD
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-4836
Practice Address - Country:US
Practice Address - Phone:843-215-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34181223G0001X
SC100221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice