Provider Demographics
NPI:1982305454
Name:SHEPARD FAMILY DENTISTRY, P.C.
Entity Type:Organization
Organization Name:SHEPARD FAMILY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:ROLAND
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-421-0770
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental