Healthcare Provider Details

I. General information

NPI: 1275513848
Provider Name (Legal Business Name): ASKOLD ROMAN WYNNYKIW D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 OSBORNE RD
LOUDONVILLE NY
12211-1660
US

IV. Provider business mailing address

351 OSBORNE RD
LOUDONVILLE NY
12211-1660
US

V. Phone/Fax

Practice location:
  • Phone: 518-432-3991
  • Fax: 518-432-3987
Mailing address:
  • Phone: 518-432-3991
  • Fax: 518-432-3987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number041258
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: