MEDICARE: TETYANA KORCHYNSKYY DMD, MSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	00204187	CO

General Provider Information

NPI Number	:	1003439266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TETYANA KORCHYNSKYY DMD, MSD

Provider Business Mailing Address
First Line	:	1694 E CHEYENNE MOUNTAIN BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1694 E CHEYENNE MOUNTAIN BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4050
Country	:	US
Telephone Number	:	719-538-4671
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2020
Last Update Date	:	05/22/2020

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