Provider Demographics
NPI:1942292941
Name:ISRAELIAN, SHOMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHOMER
Middle Name:
Last Name:ISRAELIAN
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 1:14102 70TH RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1937
Mailing Address - Country:US
Mailing Address - Phone:718-544-9410
Mailing Address - Fax:718-544-3091
Practice Address - Street 1:1250 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5155
Practice Address - Country:US
Practice Address - Phone:718-648-5265
Practice Address - Fax:718-758-3563
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0454511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01872893Medicaid