Provider Demographics
NPI:1336547926
Name:KEVIN BRENT SHEDLOCK, DDS, PC
Entity Type:Organization
Organization Name:KEVIN BRENT SHEDLOCK, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:SHEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-320-0455
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:GLENNALLEN
Mailing Address - State:AK
Mailing Address - Zip Code:99588
Mailing Address - Country:US
Mailing Address - Phone:907-320-0455
Mailing Address - Fax:
Practice Address - Street 1:MILE 187 GLENN HIGHWAY
Practice Address - Street 2:
Practice Address - City:GLENNALLEN
Practice Address - State:AK
Practice Address - Zip Code:99588
Practice Address - Country:US
Practice Address - Phone:907-320-0455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1001261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1912241704Medicaid