Provider Demographics
NPI:1639186257
Name:KATHLEEN S. SHEPARD, D.D.S., INC.
Entity Type:Organization
Organization Name:KATHLEEN S. SHEPARD, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:SUZETTE
Authorized Official - Last Name:DUBOSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:513-851-0044
Mailing Address - Street 1:6 TRIANGLE PARK DR
Mailing Address - Street 2:SUITE 603
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3403
Mailing Address - Country:US
Mailing Address - Phone:513-851-0044
Mailing Address - Fax:513-851-9130
Practice Address - Street 1:6 TRIANGLE PARK DR
Practice Address - Street 2:SUITE 603
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3403
Practice Address - Country:US
Practice Address - Phone:513-851-0044
Practice Address - Fax:513-851-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH195051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0229952Medicaid