Provider Demographics
NPI:1942470331
Name:JOHN SHEA D.D.S. LLC
Entity Type:Organization
Organization Name:JOHN SHEA D.D.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:VE
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-782-4054
Mailing Address - Street 1:615 10TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4768
Mailing Address - Country:US
Mailing Address - Phone:608-782-4054
Mailing Address - Fax:608-782-2198
Practice Address - Street 1:615 10TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4768
Practice Address - Country:US
Practice Address - Phone:608-782-4054
Practice Address - Fax:608-782-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33463300Medicaid