MEDICARE: DR. SHANE G METHAL DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	047595-1	NY

General Provider Information

NPI Number	:	1316034317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANE G METHAL DDS

Provider Business Mailing Address
First Line	:	PO BOX 172
Second Line	:
City	:	EAST ROCKAWAY
State	:	NY
Zip	:	11518-0172
Country	:	US
Telephone Number	:	646-515-5599
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 W 79TH ST
Second Line	:	SUITE 301
City	:	NEW YORK
State	:	NY
Zip	:	10024-6480
Country	:	US
Telephone Number	:	212-496-9600
Fax Number	:	212-496-9788

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. SHANE G METHAL DDS” Practice Location

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