Healthcare Provider Details

I. General information

NPI: 1740801679
Provider Name (Legal Business Name): DANIEL KHODORKOVSKY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E 60TH ST STE 608
NEW YORK NY
10022-1038
US

IV. Provider business mailing address

100 OLD PALISADE RD APT 3711
FORT LEE NJ
07024-7028
US

V. Phone/Fax

Practice location:
  • Phone: 347-566-0219
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number062684-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: