Provider Demographics
NPI:1598831083
Name:JAHANSHAHI, POURANG
Entity Type:Individual
Prefix:
First Name:POURANG
Middle Name:
Last Name:JAHANSHAHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 5TH AVE, APT 4E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215
Mailing Address - Country:US
Mailing Address - Phone:303-726-1699
Mailing Address - Fax:
Practice Address - Street 1:39-05 61ST STREET, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11137
Practice Address - Country:US
Practice Address - Phone:917-279-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053313-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics