Healthcare Provider Details

I. General information

NPI: 1487727756
Provider Name (Legal Business Name): SHYLON T MATHEW D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 RIDGE RD W
ROCHESTER NY
14615-2405
US

IV. Provider business mailing address

18 HIGH MANOR DR APT. 1
HENRIETTA NY
14467-9109
US

V. Phone/Fax

Practice location:
  • Phone: 585-865-6691
  • Fax:
Mailing address:
  • Phone: 973-615-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number053101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: