Provider Demographics
NPI:1164616439
Name:SHADOUD, SUHAIL (DDS)
Entity Type:Individual
Prefix:
First Name:SUHAIL
Middle Name:
Last Name:SHADOUD
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 1:610 W 185TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3101
Mailing Address - Country:US
Mailing Address - Phone:212-927-4343
Mailing Address - Fax:212-740-2027
Practice Address - Street 1:610 W 185TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3101
Practice Address - Country:US
Practice Address - Phone:212-927-4343
Practice Address - Fax:212-740-2027
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049886122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249416Medicaid