Provider Demographics
NPI:1093961807
Name:DRS SHTURMAN AND KISILYUK INC
Entity Type:Organization
Organization Name:DRS SHTURMAN AND KISILYUK INC
Other - Org Name:DENTAL MEDICINE PROVIDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHTURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-343-4477
Mailing Address - Street 1:100 S ELLSWORTH AVE
Mailing Address - Street 2:STE 809
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3939
Mailing Address - Country:US
Mailing Address - Phone:650-343-4477
Mailing Address - Fax:650-343-4412
Practice Address - Street 1:100 S ELLSWORTH AVE
Practice Address - Street 2:STE 809
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3939
Practice Address - Country:US
Practice Address - Phone:650-343-4477
Practice Address - Fax:650-343-4412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6387750002Medicare NSC
CA6387750001Medicare NSC