=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821587569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHYLON MATHEW DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2018
-----------------------------------------------------
Last Update Date | 08/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 GARDEN CITY PLZ STE 101
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-3337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-916-7755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8315 255TH ST
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11004-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-539-3311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 060605
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------