Provider Demographics
NPI:1700875077
Name:SHEPARD, CLAYTON ROLAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:ROLAND
Last Name:SHEPARD
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 1:3911 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2520
Mailing Address - Country:US
Mailing Address - Phone:763-421-0770
Mailing Address - Fax:763-421-0772
Practice Address - Street 1:3911 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2520
Practice Address - Country:US
Practice Address - Phone:763-421-0770
Practice Address - Fax:763-421-0772
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10035MN1223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN320022100OtherMEDICAL ASSISTANCE N UMBE
MN10035MNOtherDENTAL LICENSE NUMBER
BS0780785OtherDEA NUMBER