Provider Demographics
NPI:1083776702
Name:SHAEV, SANFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:
Last Name:SHAEV
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 1:515 E 79TH ST
Mailing Address - Street 2:10B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-0705
Mailing Address - Country:US
Mailing Address - Phone:212-288-8148
Mailing Address - Fax:
Practice Address - Street 1:105 STEVENS AVE
Practice Address - Street 2:606
Practice Address - City:MT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2686
Practice Address - Country:US
Practice Address - Phone:914-699-6191
Practice Address - Fax:914-699-1502
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0284931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00284804Medicaid