Provider Demographics
NPI:1467010314
Name:SHEA, JACOB (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
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 1:8124 CAMBRIDGE RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-5515
Mailing Address - Country:US
Mailing Address - Phone:702-271-5506
Mailing Address - Fax:
Practice Address - Street 1:2964 MILLER PLACE WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-1673
Practice Address - Country:US
Practice Address - Phone:865-770-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist