Healthcare Provider Details

I. General information

NPI: 1477950467
Provider Name (Legal Business Name): DMITRIY KUZNETSOV D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 E 15TH ST APT 1E
NEW YORK NY
10003-3532
US

IV. Provider business mailing address

145 E 15TH ST APT 1E
NEW YORK NY
10003-3532
US

V. Phone/Fax

Practice location:
  • Phone: 212-475-7947
  • Fax: 212-475-7952
Mailing address:
  • Phone: 212-475-7947
  • Fax: 212-475-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number058145
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: