Healthcare Provider Details

I. General information

NPI: 1720076979
Provider Name (Legal Business Name): IMAN SHAHINE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7770 FRONTAGE RD
CICERO NY
13039-8600
US

IV. Provider business mailing address

628 BRADFORD PKWY
DEWITT NY
13214
US

V. Phone/Fax

Practice location:
  • Phone: 315-458-3088
  • Fax: 315-458-5382
Mailing address:
  • Phone: 315-458-3088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number051526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: