Healthcare Provider Details

I. General information

NPI: 1871086694
Provider Name (Legal Business Name): SHUO YANG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 9TH ST APT 310
MEDFORD MA
02155
US

IV. Provider business mailing address

8 9TH ST APT 310
MEDFORD MA
02155-5169
US

V. Phone/Fax

Practice location:
  • Phone: 781-975-8413
  • Fax:
Mailing address:
  • Phone: 781-975-8413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1857997
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: