Provider Demographics
NPI:1700464443
Name:MAO, SHIYUAN (DMD)
Entity Type:Individual
Prefix:
First Name:SHIYUAN
Middle Name:
Last Name:MAO
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 1:130 GRANITE ST STE C
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2461
Mailing Address - Country:US
Mailing Address - Phone:401-596-8720
Mailing Address - Fax:
Practice Address - Street 1:130 GRANITE ST STE C
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2461
Practice Address - Country:US
Practice Address - Phone:401-596-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN036711223P0221X
CT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223P0221XDental ProvidersDentistPediatric Dentistry