Healthcare Provider Details

I. General information

NPI: 1689171746
Provider Name (Legal Business Name): TARAS KULYNYCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 06/21/2023
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 SAINT JOHNS PKWY STE 102
ST JOHNS FL
32259-4593
US

IV. Provider business mailing address

10383 AVENTURA DR
JACKSONVILLE FL
32256-5841
US

V. Phone/Fax

Practice location:
  • Phone: 904-506-0097
  • Fax:
Mailing address:
  • Phone: 914-494-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN23831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: