MEDICARE: DR. KOOROSH SHAMTOUB DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	051063	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205819919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KOOROSH SHAMTOUB DDS

Provider Business Mailing Address
First Line	:	1350 OCEAN PKWY
Second Line	:	#4J
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5659
Country	:	US
Telephone Number	:	718-375-1731
Fax Number	:

Provider Business Practice Location Address
First Line	:	9413 FLATLANDS AVE
Second Line	:	STE 102W
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3707
Country	:	US
Telephone Number	:	718-257-0300
Fax Number	:	718-257-0670

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	07/08/2007

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