Provider Demographics
NPI:1902951478
Name:MATHEW, RANI SUSAN (DDS)
Entity type:Individual
Prefix:
First Name:RANI
Middle Name:SUSAN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20815 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-1711
Mailing Address - Country:US
Mailing Address - Phone:718-468-5300
Mailing Address - Fax:718-301-5832
Practice Address - Street 1:20815 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1711
Practice Address - Country:US
Practice Address - Phone:718-468-5300
Practice Address - Fax:718-301-5832
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02321277Medicaid