Provider Demographics
NPI:1558940460
Name:SALOMON, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:SALOMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 SUNNYSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-2227
Mailing Address - Country:US
Mailing Address - Phone:914-819-2833
Mailing Address - Fax:
Practice Address - Street 1:3130 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1517
Practice Address - Country:US
Practice Address - Phone:845-284-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY062929-01122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program