Basic Information
Provider Information
NPI: 1003015926
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHAPIRO
FirstName: SLAVA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS, MD
OtherOrganizationName:  
OtherOrganizationType:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 167 FROEHLICH FARM BLVD
Address2:  
City: WOODBURY
State: NY
PostalCode: 117972906
CountryCode: US
TelephoneNumber: 9178378023
FaxNumber:  
Practice Location
Address1: 118 GREENWAY DR S
Address2:  
City: SYOSSET
State: NY
PostalCode: 117913854
CountryCode: US
TelephoneNumber: 9178378023
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/11/2007
LastUpdateDate: 07/05/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X049812-1NYN Dental ProvidersDentistGeneral Practice
1223S0112X049812-1NYY Dental ProvidersDentistOral and Maxillofacial Surgery

ID Information
IDTypeStateIssuerDescription
0249156905NY MEDICAID
26-264544301 EMPLOYER IDENTIFICATION NUMBEROTHER


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