Provider Demographics
NPI:1205819919
Name:SHAMTOUB, KOOROSH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KOOROSH
Middle Name:
Last Name:SHAMTOUB
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 1:1350 OCEAN PKWY
Mailing Address - Street 2:#4J
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5659
Mailing Address - Country:US
Mailing Address - Phone:718-375-1731
Mailing Address - Fax:
Practice Address - Street 1:9413 FLATLANDS AVE
Practice Address - Street 2:STE 102W
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3707
Practice Address - Country:US
Practice Address - Phone:718-257-0300
Practice Address - Fax:718-257-0670
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0510631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02496220Medicaid