Provider Demographics
NPI:1972212389
Name:SHAO, RICHARD RONGQUAN
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:RONGQUAN
Last Name:SHAO
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 1:14962 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-1709
Mailing Address - Country:US
Mailing Address - Phone:646-886-6889
Mailing Address - Fax:
Practice Address - Street 1:984 N BROADWAY STE 410
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1308
Practice Address - Country:US
Practice Address - Phone:914-476-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023512-01124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist