Provider Demographics
NPI:1831180876
Name:SHAFIQUE, MOHAMMAD (DDS)
Entity type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:
Last Name:SHAFIQUE
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 1:1591 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-1002
Mailing Address - Country:US
Mailing Address - Phone:718-574-4961
Mailing Address - Fax:718-443-8669
Practice Address - Street 1:718 KNICKERBOCKER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-5333
Practice Address - Country:US
Practice Address - Phone:718-574-9915
Practice Address - Fax:718-574-3333
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038023122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00801501Medicaid