Provider Demographics
NPI:1083721906
Name:SHEHAN, MARK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:SHEHAN
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 1:1601 SOUTH HAWTHORNE ROAD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4127
Mailing Address - Country:US
Mailing Address - Phone:336-765-9550
Mailing Address - Fax:336-765-9552
Practice Address - Street 1:1601 SOUTH HAWTHORNE ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4127
Practice Address - Country:US
Practice Address - Phone:336-765-9550
Practice Address - Fax:336-765-9552
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC49491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7997761Medicaid
NC241381Medicare ID - Type Unspecified
T95442Medicare UPIN