Healthcare Provider Details

I. General information

NPI: 1235510967
Provider Name (Legal Business Name): MATTHEW BERNARD SHAUGHNESSY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2962 STATE ROUTE 39
MILLERSBURG OH
44654-8852
US

IV. Provider business mailing address

9250 BEECHWOOD DR
BRECKSVILLE OH
44141-2647
US

V. Phone/Fax

Practice location:
  • Phone: 330-893-3363
  • Fax:
Mailing address:
  • Phone: 708-362-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033443
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.24891
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: