Provider Demographics
NPI:1558351403
Name:SHEA, KYRA Y (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYRA
Middle Name:Y
Last Name:SHEA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 WINDLAKE DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4812
Mailing Address - Country:US
Mailing Address - Phone:323-491-9989
Mailing Address - Fax:
Practice Address - Street 1:340 BOATNER RD BLDG 2751
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:508-883-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035916122300000X
CA567361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist