Provider Demographics
NPI:1487640082
Name:SHAHRAM SHEKIB, DDS, FAGD, PC
Entity Type:Organization
Organization Name:SHAHRAM SHEKIB, DDS, FAGD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEKIB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-435-0045
Mailing Address - Street 1:1671 55TH ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1824
Mailing Address - Country:US
Mailing Address - Phone:718-435-0045
Mailing Address - Fax:718-435-1260
Practice Address - Street 1:1671 55TH ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1824
Practice Address - Country:US
Practice Address - Phone:718-435-0045
Practice Address - Fax:718-435-1260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01873069Medicaid
NYDE7281Medicare ID - Type UnspecifiedPROVIDER #