Provider Demographics
NPI:1194749390
Name:SHEA, STEPHEN (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:SHEA
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 1:2400 COMPUTER DR
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-1770
Mailing Address - Country:US
Mailing Address - Phone:508-329-2250
Mailing Address - Fax:508-329-2255
Practice Address - Street 1:275 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1931
Practice Address - Country:US
Practice Address - Phone:978-665-5820
Practice Address - Fax:978-665-5808
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12915201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1319833Medicaid