Provider Demographics
NPI:1790475465
Name:SHEPHERD, CAMERON STONE
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:STONE
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4972 E 62ND AVE UNIT B1
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-3253
Mailing Address - Country:US
Mailing Address - Phone:303-288-4969
Mailing Address - Fax:
Practice Address - Street 1:4972 E 62ND AVE UNIT B1
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-3253
Practice Address - Country:US
Practice Address - Phone:303-288-4969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28070122300000X
CODEN.00205677122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist