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General NPI Number Information
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NPI Number | 1730628884
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Entity Type | Organization
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Legal Business Name | GLEN SHANOCK'S DENTISTRY, PC
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Dates
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Enumeration Date | 02/21/2017
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Last Update Date | 02/21/2017
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Provider Practice Location Address
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Address Line | 120 W PARK AVE SUITE 301
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City | LONG BEACH
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State | NY
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Zip | 11561-3301
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Country | US
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Telephone | 516-431-5855
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Fax | 516-431-0728
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Provider Business Mailing Address
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Address Line | 120 W PARK AVE SUITE 301
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City | LONG BEACH
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State | NY
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Zip | 11561-3301
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Country | US
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Telephone | 516-431-5855
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Fax | 516-431-0728
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Authorized Official
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Title or Position | OWNER
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Name | DR. GLEN SHANOCK
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Credential | DDS
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Telephone | 516-431-5855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 045836
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License Number State | NY
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