MEDICARE: IDA ANJOMSHOAA

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	058065	NY

General Provider Information

NPI Number	:	1316284763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDA ANJOMSHOAA

Provider Business Mailing Address
First Line	:	306 MOTT ST
Second Line	:	APT #4C
City	:	NEW YORK
State	:	NY
Zip	:	10012
Country	:	US
Telephone Number	:	718-899-7811
Fax Number	:

Provider Business Practice Location Address
First Line	:	3353 82ND ST
Second Line	:	A01
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-1447
Country	:	US
Telephone Number	:	718-899-7811
Fax Number	:

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

Provider Enumeration Date	:	01/04/2013
Last Update Date	:	03/17/2016

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