Provider Demographics
NPI:1558497529
Name:EVAN P. MONDSHINE, D.D.S., P.C.
Entity Type:Organization
Organization Name:EVAN P. MONDSHINE, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MONDSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-268-1561
Mailing Address - Street 1:6836 108TH ST STE 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 STE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031513122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00339946Medicaid