Provider Demographics
NPI:1669527685
Name:IM, PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:IM
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 1:252-20 NORTHERN BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362
Mailing Address - Country:US
Mailing Address - Phone:718-224-9453
Mailing Address - Fax:718-224-9455
Practice Address - Street 1:25220 NORTHERN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1344
Practice Address - Country:US
Practice Address - Phone:718-224-9453
Practice Address - Fax:718-224-9455
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047682-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
05940Medicare ID - Type Unspecified
U97113Medicare UPIN