Provider Demographics
NPI:1245220078
Name:SHANIK, KENNETH VICTOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:VICTOR
Last Name:SHANIK
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 1:44 ELM ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3403
Mailing Address - Country:US
Mailing Address - Phone:631-427-0470
Mailing Address - Fax:631-427-0504
Practice Address - Street 1:44 ELM ST
Practice Address - Street 2:SUITE 6
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3403
Practice Address - Country:US
Practice Address - Phone:631-427-0470
Practice Address - Fax:631-427-0504
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0318521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice