Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 06136301 | NY |
NPI | 1003375759 |
---|---|
Provider Name | Israel Shimunov |
First Address | Forest Hills, NY 11375-1314 |
Second Address | Rego Park, NY 11374-3505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2019 |
Last Update Date | 10/06/2021 |