Provider Demographics
NPI:1285857813
Name:SHEA, BRIAN MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MARK
Last Name:SHEA
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 1:39 COCHATO ROAD
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4628
Mailing Address - Country:US
Mailing Address - Phone:781-356-6755
Mailing Address - Fax:
Practice Address - Street 1:335 COREY STREET
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-1614
Practice Address - Country:US
Practice Address - Phone:617-327-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice