Healthcare Provider Details

I. General information

NPI: 1215221874
Provider Name (Legal Business Name): ANDREW KUZNETSOV D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 1ST AVE APT 2
NEW HYDE PARK NY
11040-4815
US

IV. Provider business mailing address

600 1ST AVE APT 2
NEW HYDE PARK NY
11040-4815
US

V. Phone/Fax

Practice location:
  • Phone: 718-404-8985
  • Fax:
Mailing address:
  • Phone: 718-404-8985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number055500
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: