Healthcare Provider Details

I. General information

NPI: 1467513200
Provider Name (Legal Business Name): OLEG ZUSIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 GRANT AVE
PELHAM NY
10803-3440
US

IV. Provider business mailing address

1140 GRANT AVE
PELHAM NY
10803-3440
US

V. Phone/Fax

Practice location:
  • Phone: 917-968-5238
  • Fax: 914-533-3443
Mailing address:
  • Phone: 917-968-5238
  • Fax: 914-533-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number047194
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: