Provider Demographics
NPI:1710548656
Name:SANTOS, SHEA NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHEA
Middle Name:NICOLE
Last Name:SANTOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N AUSTIN AVE APT 1102
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-4240
Mailing Address - Country:US
Mailing Address - Phone:682-365-2958
Mailing Address - Fax:
Practice Address - Street 1:7410 W ADAMS AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-5891
Practice Address - Country:US
Practice Address - Phone:254-406-6066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist