Provider Demographics
NPI:1528197548
Name:SHEPHERD, JACK W (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:SHEPHERD
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 1:110 POCAHONTAS TRL
Mailing Address - Street 2:SUITE E
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1167
Mailing Address - Country:US
Mailing Address - Phone:502-863-4651
Mailing Address - Fax:
Practice Address - Street 1:110 POCAHONTAS TRL
Practice Address - Street 2:SUITE E
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1167
Practice Address - Country:US
Practice Address - Phone:502-863-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist