Provider Demographics
NPI:1912241704
Name:SHEDLOCK, KEVIN BRENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRENT
Last Name:SHEDLOCK
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:PO BOX 744
Mailing Address - Street 2:
Mailing Address - City:GLENNALLEN
Mailing Address - State:AK
Mailing Address - Zip Code:99588-0744
Mailing Address - Country:US
Mailing Address - Phone:907-822-3113
Mailing Address - Fax:
Practice Address - Street 1:MILE 187.5 GLENN HWY
Practice Address - Street 2:
Practice Address - City:GLENNALLEN
Practice Address - State:AK
Practice Address - Zip Code:99588
Practice Address - Country:US
Practice Address - Phone:907-822-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA1001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist