Provider Demographics
NPI:1679819882
Name:SHEA, THOMAS ALPHONSUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALPHONSUS
Last Name:SHEA
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 1:42 WOODBURY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4132
Mailing Address - Country:US
Mailing Address - Phone:631-271-3903
Mailing Address - Fax:631-470-4569
Practice Address - Street 1:42 WOODBURY RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4132
Practice Address - Country:US
Practice Address - Phone:631-271-3903
Practice Address - Fax:631-470-4569
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist