Provider Demographics
NPI:1447098132
Name:CANARSIE MODERN DENTISTRY PLLC
Entity type:Organization
Organization Name:CANARSIE MODERN DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOOROSH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMTOUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-257-0300
Mailing Address - Street 1:9413 FLATLANDS AVE STE 102W
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3713
Mailing Address - Country:US
Mailing Address - Phone:718-257-0300
Mailing Address - Fax:
Practice Address - Street 1:9413 FLATLANDS AVE STE 102W
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3713
Practice Address - Country:US
Practice Address - Phone:718-257-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty