Provider Demographics
NPI:1609044023
Name:LS DENTAL PC
Entity Type:Organization
Organization Name:LS DENTAL PC
Other - Org Name:LS DENTAL PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIMANOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-752-9000
Mailing Address - Street 1:4705 44TH ST APT A2
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-6301
Mailing Address - Country:US
Mailing Address - Phone:718-752-9000
Mailing Address - Fax:718-440-9460
Practice Address - Street 1:4705 44TH ST APT A2
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-6301
Practice Address - Country:US
Practice Address - Phone:718-752-9000
Practice Address - Fax:718-440-9460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048978-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02259492Medicaid