Provider Demographics
NPI:1932464997
Name:CICCARESE, SHEEDE KHALIL
Entity Type:Individual
Prefix:DR
First Name:SHEEDE
Middle Name:KHALIL
Last Name:CICCARESE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SHEEDE
Other - Middle Name:KHALIL
Other - Last Name:CICCARESE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 E NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST FL 7
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL11601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist