Provider Demographics
NPI:1871696427
Name:SHEPHERD, WALTER BRIAN (DDS MS)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:BRIAN
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:WALTER SHEPHERD DDS MS
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289
Mailing Address - Country:US
Mailing Address - Phone:336-627-5163
Mailing Address - Fax:
Practice Address - Street 1:113 E MOORE ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27289
Practice Address - Country:US
Practice Address - Phone:336-627-5163
Practice Address - Fax:336-627-5165
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0141131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997773Medicaid
VA078247OtherBCBS INSURANCE OF VA