Healthcare Provider Details

I. General information

NPI: 1811202633
Provider Name (Legal Business Name): RABIE M SHANTI DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST RM B-854
NEWARK NJ
07103-2495
US

IV. Provider business mailing address

110 BERGEN ST RM B-854
NEWARK NJ
07103-2495
US

V. Phone/Fax

Practice location:
  • Phone: 739-972-3126
  • Fax: 973-972-7322
Mailing address:
  • Phone: 739-972-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberMD458380
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD458380
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberMD458380
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number22DI02438500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: