Provider Demographics
NPI:1871647677
Name:SHAMALOVA, IRINA (DDS)
Entity type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:SHAMALOVA
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 1:9941 64TH AVE
Mailing Address - Street 2:APT. A12
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2653
Mailing Address - Country:US
Mailing Address - Phone:917-749-6330
Mailing Address - Fax:212-410-6989
Practice Address - Street 1:2071 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4101
Practice Address - Country:US
Practice Address - Phone:212-410-6969
Practice Address - Fax:212-410-6989
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052022-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02771093Medicaid
NY9184884OtherDORAL