Healthcare Provider Details

I. General information

NPI: 1982168845
Provider Name (Legal Business Name): IDA GORSHTEYN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 10TH AVE APT 4
SAN FRANCISCO CA
94122-3665
US

IV. Provider business mailing address

283 PARKER AVE APT C
SAN FRANCISCO CA
94118-3365
US

V. Phone/Fax

Practice location:
  • Phone: 408-438-7332
  • Fax:
Mailing address:
  • Phone: 408-438-7332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDDS104659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: