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General NPI Number Information
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NPI Number | 1316284763
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Entity Type | Individual
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Provider Name | IDA ANJOMSHOAA
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Gender | Female
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Dates
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Enumeration Date | 01/04/2013
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Last Update Date | 03/17/2016
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Provider Practice Location Address
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Address Line | 3353 82ND ST A01
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City | JACKSON HEIGHTS
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State | NY
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Zip | 11372-1447
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Country | US
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Telephone | 718-899-7811
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Fax |
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Provider Business Mailing Address
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Address Line | 306 MOTT ST APT #4C
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City | NEW YORK
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State | NY
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Zip | 10012
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Country | US
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Telephone | 718-899-7811
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 058065
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License Number State | NY
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