Provider Demographics
NPI:1639722937
Name:BENZAQUEN, SHALOM ISRAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHALOM
Middle Name:ISRAEL
Last Name:BENZAQUEN
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 1:3-433 MAPLE STREET, APARTMENT #3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225
Mailing Address - Country:US
Mailing Address - Phone:929-293-7051
Mailing Address - Fax:
Practice Address - Street 1:585 SCHENECTADY AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203
Practice Address - Country:US
Practice Address - Phone:718-604-5381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program