Provider Demographics
NPI:1821130329
Name:SHABALA, YELENA (DDS)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:SHABALA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SPRUCE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-3529
Mailing Address - Country:US
Mailing Address - Phone:201-792-7479
Mailing Address - Fax:
Practice Address - Street 1:1537 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2908
Practice Address - Country:US
Practice Address - Phone:718-617-0624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22DI023357001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02783544Medicaid