MEDICARE: DR. PAUL IM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	047682-1	NY

General Provider Information

NPI Number	:	1669527685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL IM DDS

Provider Business Mailing Address
First Line	:	252-20 NORTHERN BLVD
Second Line	:	SUITE 200
City	:	LITTLE NECK
State	:	NY
Zip	:	11362
Country	:	US
Telephone Number	:	718-224-9453
Fax Number	:	718-224-9455

Provider Business Practice Location Address
First Line	:	25220 NORTHERN BLVD STE 200
Second Line	:
City	:	LITTLE NECK
State	:	NY
Zip	:	11362-1344
Country	:	US
Telephone Number	:	718-224-9453
Fax Number	:	718-224-9455

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	01/24/2012

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