Provider Demographics
NPI:1376549352
Name:SHEEHAN, GREGORY MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:SHEEHAN
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 1:1215 RICE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4538
Mailing Address - Country:US
Mailing Address - Phone:651-488-7251
Mailing Address - Fax:651-488-7252
Practice Address - Street 1:1215 RICE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-4538
Practice Address - Country:US
Practice Address - Phone:651-488-7251
Practice Address - Fax:651-488-7252
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN83931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4030184Medicaid