Basic Information
| Provider Information | |||||||||
| NPI: | 1003015926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAPIRO | ||||||||
| FirstName: | SLAVA | ||||||||
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| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 167 FROEHLICH FARM BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117972906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178378023 | ||||||||
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| Practice Location | |||||||||
| Address1: | 118 GREENWAY DR S | ||||||||
| Address2: | |||||||||
| City: | SYOSSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117913854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178378023 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 07/05/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 049812-1 | NY | N | Dental Providers | Dentist | General Practice | 1223S0112X | 049812-1 | NY | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02491569 | 05 | NY | MEDICAID |