Provider Demographics
NPI:1568587749
Name:SHEA, DANIEL T (RDO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:SHEA
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2110 DORCHESTER AVE
Mailing Address - Street 2:#100
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5628
Mailing Address - Country:US
Mailing Address - Phone:617-298-5300
Mailing Address - Fax:617-296-3028
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:#100
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:617-298-5300
Practice Address - Fax:617-296-3028
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1698156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician