Healthcare Provider Details

I. General information

NPI: 1083721906
Provider Name (Legal Business Name): MARK T SHEHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SOUTH HAWTHORNE ROAD
WINSTON SALEM NC
27103-4127
US

IV. Provider business mailing address

1601 SOUTH HAWTHORNE ROAD
WINSTON SALEM NC
27103-4127
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-9550
  • Fax: 336-765-9552
Mailing address:
  • Phone: 336-765-9550
  • Fax: 336-765-9552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4949
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: