Healthcare Provider Details

I. General information

NPI: 1396281135
Provider Name (Legal Business Name): LILIYA ETKINA DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4528 21ST STREET
LONG ISLAND CITY NY
11101
US

IV. Provider business mailing address

45-28 21ST STREET
LONG ISLAND CITY NY
11101
US

V. Phone/Fax

Practice location:
  • Phone: 718-937-7722
  • Fax:
Mailing address:
  • Phone: 718-937-7722
  • Fax: 718-937-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberC50603
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number057328
License Number StateNY

VIII. Authorized Official

Name: LILIYA ETKINA
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 718-937-7722