Healthcare Provider Details

I. General information

NPI: 1922109768
Provider Name (Legal Business Name): JOHN RICHARD SHURE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12210 ROCKAWAY BEACH BLVD
ROCKAWAY PARK NY
11694-1836
US

IV. Provider business mailing address

12210 ROCKAWAY BEACH BLVD
ROCKAWAY PARK NY
11694-1836
US

V. Phone/Fax

Practice location:
  • Phone: 718-634-9700
  • Fax: 718-474-7330
Mailing address:
  • Phone: 718-634-9700
  • Fax: 718-474-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number31435
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: