Provider Demographics
NPI:1003375759
Name:SHIMUNOV, ISRAEL (DDS)
Entity Type:Individual
Prefix:
First Name:ISRAEL
Middle Name:
Last Name:SHIMUNOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6259 108TH ST APT 5H
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1314
Mailing Address - Country:US
Mailing Address - Phone:347-247-6810
Mailing Address - Fax:
Practice Address - Street 1:9815 65TH RD APT 1B
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3505
Practice Address - Country:US
Practice Address - Phone:347-247-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY06136301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program