Provider Demographics
NPI:1245492933
Name:SHEPHERD, RYAN S (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:S
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6123 PURPLE ASTER LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8082
Mailing Address - Country:US
Mailing Address - Phone:505-544-1043
Mailing Address - Fax:
Practice Address - Street 1:7111 PROSPECT PL NE
Practice Address - Street 2:SUITE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4309
Practice Address - Country:US
Practice Address - Phone:505-268-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2998122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist