Provider Demographics
NPI:1104372788
Name:SHEALY, THOMAS RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RYAN
Last Name:SHEALY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 HILL ST
Mailing Address - Street 2:
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207
Mailing Address - Country:US
Mailing Address - Phone:803-751-6209
Mailing Address - Fax:803-751-6886
Practice Address - Street 1:8930 BROWN DR BLDG 92ND
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5629
Practice Address - Country:US
Practice Address - Phone:301-319-0217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32677122300000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No122300000XDental ProvidersDentist