Provider Demographics
NPI:1619067675
Name:PARK, SHANY C (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANY
Middle Name:C
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 QUAKER RIDGE RD
Mailing Address - Street 2:#202
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-2808
Mailing Address - Country:US
Mailing Address - Phone:914-636-5958
Mailing Address - Fax:
Practice Address - Street 1:77 QUAKER RIDGE RD
Practice Address - Street 2:#202
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804-2808
Practice Address - Country:US
Practice Address - Phone:914-636-5958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048040-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics