Healthcare Provider Details

I. General information

NPI: 1902992258
Provider Name (Legal Business Name): OLGA BUKHOLTS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BROADWAY CITY DENTAL GROUP
NEW YORK NY
10004-1303
US

IV. Provider business mailing address

20 W 64TH ST APT 32E
NEW YORK NY
10023-7138
US

V. Phone/Fax

Practice location:
  • Phone: 212-425-0505
  • Fax: 212-425-2120
Mailing address:
  • Phone: 646-361-3633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number048802
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: