Provider Demographics
NPI:1679772602
Name:SHEPHERD, RICHARD W (DDS, PS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:DDS, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 CEMETARY RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9303
Mailing Address - Country:US
Mailing Address - Phone:360-785-4755
Mailing Address - Fax:360-785-3336
Practice Address - Street 1:617 CEMETARY RD
Practice Address - Street 2:
Practice Address - City:WINLOCK
Practice Address - State:WA
Practice Address - Zip Code:98596-9303
Practice Address - Country:US
Practice Address - Phone:360-785-4755
Practice Address - Fax:360-785-3336
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000043041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA29532OtherL & I
WA539-3608Medicaid