Healthcare Provider Details

I. General information

NPI: 1700464443
Provider Name (Legal Business Name): SHIYUAN MAO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GRANITE ST STE C
WESTERLY RI
02891-2461
US

IV. Provider business mailing address

130 GRANITE ST STE C
WESTERLY RI
02891-2461
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-8720
  • Fax:
Mailing address:
  • Phone: 401-596-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN2000475
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number13933
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN03671
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: