Healthcare Provider Details

I. General information

NPI: 1548793201
Provider Name (Legal Business Name): SHAUN FREDERICK DARRAH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 S LAKE BLVD
MAHOPAC NY
10541-3254
US

IV. Provider business mailing address

1133 WARBURTON AVE APT 604N
YONKERS NY
10701-1131
US

V. Phone/Fax

Practice location:
  • Phone: 845-621-2424
  • Fax:
Mailing address:
  • Phone: 631-398-9376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number060522
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: