Provider Demographics
NPI:1639203078
Name:TABANKIA, PAYAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAYAM
Middle Name:
Last Name:TABANKIA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E 29TH ST APT 6I
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6204
Mailing Address - Country:US
Mailing Address - Phone:818-438-3982
Mailing Address - Fax:
Practice Address - Street 1:690 BAY ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-3830
Practice Address - Country:US
Practice Address - Phone:718-727-3333
Practice Address - Fax:718-727-8321
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052797-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02782667Medicaid