Provider Demographics
NPI:1295907574
Name:WALTER B. SHEPHERD
Entity type:Organization
Organization Name:WALTER B. SHEPHERD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS PA
Authorized Official - Phone:336-627-5163
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0246
Mailing Address - Country:US
Mailing Address - Phone:336-627-5163
Mailing Address - Fax:336-627-5165
Practice Address - Street 1:113 E MOORE ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288
Practice Address - Country:US
Practice Address - Phone:336-627-5163
Practice Address - Fax:336-627-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0041131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997773Medicaid
VA078247OtherVIRGINIA BCBS