Provider Demographics
NPI:1922173582
Name:SHEPPARD, MARK WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILSON
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 SOUTHWAY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2203
Mailing Address - Country:US
Mailing Address - Phone:208-743-2792
Mailing Address - Fax:208-743-0534
Practice Address - Street 1:77 SOUTHWAY AVE STE A
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2203
Practice Address - Country:US
Practice Address - Phone:208-743-2792
Practice Address - Fax:208-743-0534
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-31371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice