Provider Demographics
NPI:1730628884
Name:GLEN SHANOCK'S DENTISTRY, PC
Entity type:Organization
Organization Name:GLEN SHANOCK'S DENTISTRY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-431-5855
Mailing Address - Street 1:120 W PARK AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3301
Mailing Address - Country:US
Mailing Address - Phone:516-431-5855
Mailing Address - Fax:516-431-0728
Practice Address - Street 1:120 W PARK AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3301
Practice Address - Country:US
Practice Address - Phone:516-431-5855
Practice Address - Fax:516-431-0728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0458361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty