Provider Demographics
NPI:1003015926
Name:SHAPIRO, SLAVA (DDS, MD)
Entity Type:Individual
Prefix:
First Name:SLAVA
Middle Name:
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 FROEHLICH FARM BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2906
Mailing Address - Country:US
Mailing Address - Phone:917-837-8023
Mailing Address - Fax:
Practice Address - Street 1:118 GREENWAY DR S
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3854
Practice Address - Country:US
Practice Address - Phone:917-837-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049812-11223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02491569Medicaid
26-2645443OtherEMPLOYER IDENTIFICATION NUMBER