Healthcare Provider Details

I. General information

NPI: 1104758317
Provider Name (Legal Business Name): SHINE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20012 44TH AVE
BAYSIDE NY
11361-2537
US

IV. Provider business mailing address

16 MARTIN CT
GREAT NECK NY
11024-1620
US

V. Phone/Fax

Practice location:
  • Phone: 929-389-1663
  • Fax:
Mailing address:
  • Phone: 516-695-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLIOT ABRAHAM SHINE
Title or Position: CEO
Credential: DDS
Phone: 516-695-0103