=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659472561
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAUN G MASSIAH DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 09/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 W 97TH STREET SUITE 16
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-6004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-222-5225
-----------------------------------------------------
Fax | 212-222-4405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 W 97TH ST APT 1C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-6004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-222-5225
-----------------------------------------------------
Fax | 212-222-4405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | SHAUN GRENVILLE MASSIAH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 212-222-5225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 047413
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------