Healthcare Provider Details

I. General information

NPI: 1740673151
Provider Name (Legal Business Name): PAUL ZHIVAGO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 04/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 E 67TH ST
NEW YORK NY
10065-6135
US

IV. Provider business mailing address

19 RYERSON PL
CLOSTER NJ
07624-2505
US

V. Phone/Fax

Practice location:
  • Phone: 212-988-2955
  • Fax:
Mailing address:
  • Phone: 646-318-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number057240-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: