Healthcare Provider Details

I. General information

NPI: 1033790621
Provider Name (Legal Business Name): MISHEL YOSHOBAIEV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE STE 304
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

10218 64TH AVE APT 5S
FOREST HILLS NY
11375-1565
US

V. Phone/Fax

Practice location:
  • Phone: 917-400-0930
  • Fax:
Mailing address:
  • Phone: 917-400-0930
  • 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 StateNY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number062845-01
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: