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General NPI Number Information
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NPI Number | 1558351403
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Entity Type | Individual
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Provider Name | KYRA Y SHEA D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/24/2005
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Last Update Date | 04/19/2023
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Provider Practice Location Address
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Address Line | 340 BOATNER RD BLDG 2751
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City | EGLIN AFB
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State | FL
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Zip | 32542-1391
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Country | US
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Telephone | 508-883-8052
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Fax |
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Provider Business Mailing Address
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Address Line | 4405 WINDLAKE DR
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City | NICEVILLE
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State | FL
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Zip | 32578-4812
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Country | US
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Telephone | 323-491-9989
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS035916
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 56736
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License Number State | CA
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