Provider Demographics
NPI:1427049907
Name:GANJIAN, SHAHROKH (DDS)
Entity type:Individual
Prefix:
First Name:SHAHROKH
Middle Name:
Last Name:GANJIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:GANJIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:9737 63RD DR
Mailing Address - Street 2:STE 1K
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2229
Mailing Address - Country:US
Mailing Address - Phone:718-897-8900
Mailing Address - Fax:718-897-6363
Practice Address - Street 1:9737 63RD DR
Practice Address - Street 2:STE 1K
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2229
Practice Address - Country:US
Practice Address - Phone:718-897-8900
Practice Address - Fax:718-897-6363
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041801122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01191097Medicaid