Provider Demographics
NPI:1306822606
Name:SHAEFER, JEFFRY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:R
Last Name:SHAEFER
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:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:188 LONGWOOD AVENUE
Practice Address - Street 2:HARVARD FACULTY GROUP PRACTICE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-432-3153
Practice Address - Fax:617-498-1205
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154021223S0112X, 1223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA015402OtherTUFTS HEALTH PLAN
MA0282138Medicaid
MA0282138Medicaid
MA015402OtherTUFTS HEALTH PLAN