Provider Demographics
NPI:1720203193
Name:KOHAN, SHAHRAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:KOHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 HAMPSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1538
Mailing Address - Country:US
Mailing Address - Phone:718-969-2120
Mailing Address - Fax:718-969-1045
Practice Address - Street 1:166-15 UNION TURPIKE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11366
Practice Address - Country:US
Practice Address - Phone:718-969-2120
Practice Address - Fax:718-969-1045
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0455901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics