Provider Demographics
NPI:1548697170
Name:SHEA, CHARLES GORDON (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GORDON
Last Name:SHEA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 VINE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901-1518
Mailing Address - Country:US
Mailing Address - Phone:814-535-7888
Mailing Address - Fax:814-539-8858
Practice Address - Street 1:225 VINE ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1518
Practice Address - Country:US
Practice Address - Phone:814-535-7888
Practice Address - Fax:814-539-8858
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018700L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015391880001Medicaid
PA0015391880001Medicaid