Basic Information
| Provider Information | |||||||||
| NPI: | 1912976309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPARD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3011 N MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667622546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202319873 | ||||||||
| FaxNumber: | 6202312808 | ||||||||
| Practice Location | |||||||||
| Address1: | 2990 MILITARY AVE | ||||||||
| Address2: | |||||||||
| City: | BAXTER SPRINGS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667132331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6208562900 | ||||||||
| FaxNumber: | 6208562901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 02/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 4864 | KS | Y | Dental Providers | Dentist |
No ID Information.