Provider Demographics
NPI:1124426788
Name:J SCOTT SHEPHERD DMD INC
Entity type:Organization
Organization Name:J SCOTT SHEPHERD DMD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:760-808-1554
Mailing Address - Street 1:2150 E TAHQUITZ CANYON WAY
Mailing Address - Street 2:SUITE #2
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-7045
Mailing Address - Country:US
Mailing Address - Phone:760-416-1003
Mailing Address - Fax:
Practice Address - Street 1:2150 E TAHQUITZ CANYON WAY
Practice Address - Street 2:SUITE #2
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-7045
Practice Address - Country:US
Practice Address - Phone:760-416-1003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51451261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental