Provider Demographics
NPI:1912049115
Name:CHARLES G SHEA DMD PC
Entity Type:Organization
Organization Name:CHARLES G SHEA DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-535-7888
Mailing Address - Street 1:225 VINE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901
Mailing Address - Country:US
Mailing Address - Phone:814-535-7888
Mailing Address - Fax:814-539-8858
Practice Address - Street 1:225 VINE ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901
Practice Address - Country:US
Practice Address - Phone:814-535-7888
Practice Address - Fax:814-539-8858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-018700-L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015391880001Medicaid
PA160535OtherBS
PA160535OtherBS
PA0015391880001Medicaid