Provider Demographics
NPI:1720076979
Name:SHAHINE, IMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:IMAN
Middle Name:
Last Name:SHAHINE
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 1:628 BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:NY
Mailing Address - Zip Code:13214
Mailing Address - Country:US
Mailing Address - Phone:315-458-3088
Mailing Address - Fax:
Practice Address - Street 1:7770 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-8600
Practice Address - Country:US
Practice Address - Phone:315-458-3088
Practice Address - Fax:315-458-5382
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02608079Medicaid