MEDICARE: JACOB SHEA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	11032	TN

General Provider Information

NPI Number	:	1467010314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB SHEA DMD

Provider Business Mailing Address
First Line	:	8124 CAMBRIDGE RESERVE DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37924-5515
Country	:	US
Telephone Number	:	702-271-5506
Fax Number	:

Provider Business Practice Location Address
First Line	:	2964 MILLER PLACE WAY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37924-1673
Country	:	US
Telephone Number	:	865-770-4477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2019
Last Update Date	:	06/04/2019

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