Provider Demographics
NPI:1043607559
Name:BLOBSTEIN, SHALOM (DMD)
Entity Type:Individual
Prefix:
First Name:SHALOM
Middle Name:
Last Name:BLOBSTEIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 FANWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3101
Mailing Address - Country:US
Mailing Address - Phone:917-450-4990
Mailing Address - Fax:
Practice Address - Street 1:845 FANWOOD AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3101
Practice Address - Country:US
Practice Address - Phone:917-450-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY058809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program