Provider Demographics
NPI:1144675406
Name:SHENOUDA, MAGED
Entity type:Individual
Prefix:MR
First Name:MAGED
Middle Name:
Last Name:SHENOUDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 KELLY BLVD.
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-757-7937
Mailing Address - Fax:
Practice Address - Street 1:177 LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-403-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-24
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0592301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty