Provider Demographics
NPI:1902292014
Name:SHIMONOVA, LYUDMILA
Entity Type:Individual
Prefix:
First Name:LYUDMILA
Middle Name:
Last Name:SHIMONOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 STEWART AVE STE 450
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4857
Mailing Address - Country:US
Mailing Address - Phone:516-362-0425
Mailing Address - Fax:
Practice Address - Street 1:990 STEWART AVE STE 450
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4857
Practice Address - Country:US
Practice Address - Phone:516-362-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0586981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery