Provider Demographics
NPI:1962623116
Name:WAHAB, SHAMEEM (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAMEEM
Middle Name:
Last Name:WAHAB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 C ROLLING RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645
Mailing Address - Country:US
Mailing Address - Phone:315-336-0494
Mailing Address - Fax:
Practice Address - Street 1:GREAT LAKES DENTAL SERVICES, PC
Practice Address - Street 2:107 E CHESTNUT ST
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-336-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01660342Medicaid