Provider Demographics
NPI:1982168845
Name:GORSHTEYN, IDA (DDS)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:GORSHTEYN
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 1:283 PARKER AVE APT C
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3365
Mailing Address - Country:US
Mailing Address - Phone:408-438-7332
Mailing Address - Fax:
Practice Address - Street 1:1463 10TH AVE APT 4
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-3665
Practice Address - Country:US
Practice Address - Phone:408-438-7332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS1046591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program