Provider Demographics
NPI:1316793375
Name:SHEA, JOHN HARRISON (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HARRISON
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 1:507 BETSY PACK DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3303
Mailing Address - Country:US
Mailing Address - Phone:423-942-5508
Mailing Address - Fax:
Practice Address - Street 1:507 BETSY PACK DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3303
Practice Address - Country:US
Practice Address - Phone:423-942-5508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN124871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice