Provider Demographics
NPI:1497012249
Name:MONDSHINE, EVAN P (DDS,PC)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:P
Last Name:MONDSHINE
Suffix:
Gender:M
Credentials:DDS,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6836 108TH ST B10
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3366
Mailing Address - Country:US
Mailing Address - Phone:718-268-1561
Mailing Address - Fax:718-268-1577
Practice Address - Street 1:6836 108TH ST B10
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3366
Practice Address - Country:US
Practice Address - Phone:718-268-1561
Practice Address - Fax:718-268-1577
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031513122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00339946Medicaid