1669894325 NPI number — SHINE ORAL AND FACIAL SURGERY ASSOCIATES P.C

Table of content: (NPI 1669894325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669894325 NPI number — SHINE ORAL AND FACIAL SURGERY ASSOCIATES P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHINE ORAL AND FACIAL SURGERY ASSOCIATES P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669894325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT NECK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11023-1133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-701-3581
Provider Business Mailing Address Fax Number:
215-750-1067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N BUCKSTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
LANGHORNE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19047-8310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-750-0200
Provider Business Practice Location Address Fax Number:
215-750-1067
Provider Enumeration Date:
01/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SOURI
Authorized Official First Name:
SAMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
917-701-3581

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DS038427 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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