Provider Demographics
NPI:1316034317
Name:METHAL, SHANE G (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:G
Last Name:METHAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:EAST ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11518-0172
Mailing Address - Country:US
Mailing Address - Phone:646-515-5599
Mailing Address - Fax:
Practice Address - Street 1:123 W 79TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6480
Practice Address - Country:US
Practice Address - Phone:212-496-9600
Practice Address - Fax:212-496-9788
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047595-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist