Provider Demographics
NPI:1558567115
Name:SHEPHERD, JOHN MURDAUGH JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MURDAUGH
Last Name:SHEPHERD
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 KINGS GRANT DR
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-3627
Mailing Address - Country:US
Mailing Address - Phone:757-898-7078
Mailing Address - Fax:
Practice Address - Street 1:5249 OLDE TOWNE RD
Practice Address - Street 2:OLDE TOWNE MEDICAL CENTER
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-8111
Practice Address - Country:US
Practice Address - Phone:757-259-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401003167122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid