Basic Information
| Provider Information | |||||||||
| NPI: | 1194749390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEA | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 COMPUTER DR | ||||||||
| Address2: | |||||||||
| City: | WESTBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015811770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083292250 | ||||||||
| FaxNumber: | 5083292255 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786655820 | ||||||||
| FaxNumber: | 9786655808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 1291520 | MA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1319833 | 05 | MA | MEDICAID |