Provider Demographics
NPI:1982719951
Name:SHEA, JOHN VICTOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VICTOR
Last Name:SHEA
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 1:8406 THREE MILE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53126
Mailing Address - Country:US
Mailing Address - Phone:262-835-4059
Mailing Address - Fax:
Practice Address - Street 1:331 E PUETZ RD
Practice Address - Street 2:#106
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154
Practice Address - Country:US
Practice Address - Phone:414-768-1020
Practice Address - Fax:414-768-8866
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33463300Medicaid