Provider Demographics
NPI:1952822249
Name:SHUKUROV, RUSTAM (DMD)
Entity Type:Individual
Prefix:
First Name:RUSTAM
Middle Name:
Last Name:SHUKUROV
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 1:9128 OLD NEWTOWN RD APT C12
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4922
Mailing Address - Country:US
Mailing Address - Phone:215-921-1279
Mailing Address - Fax:
Practice Address - Street 1:1130 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3710
Practice Address - Country:US
Practice Address - Phone:866-993-2352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist