Provider Demographics
NPI:1851731046
Name:SHAMOS, ILAN (DMD)
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:
Last Name:SHAMOS
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 1:155 W RIVERSIDE DR STE 153
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-5221
Mailing Address - Country:US
Mailing Address - Phone:928-669-0099
Mailing Address - Fax:800-341-3775
Practice Address - Street 1:155 W RIVERSIDE DR STE 153
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5221
Practice Address - Country:US
Practice Address - Phone:928-669-0099
Practice Address - Fax:800-341-3775
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist