Healthcare Provider Details

I. General information

NPI: 1891639746
Provider Name (Legal Business Name): HOLLYWOOD SMILE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9750 QUEENS BLVD STE G2
REGO PARK NY
11374-3211
US

IV. Provider business mailing address

611 BRIDGE ST
WOODMERE NY
11598-1509
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-0110
  • Fax: 718-532-0456
Mailing address:
  • Phone: 917-604-6925
  • Fax: 718-532-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. YEFIM KHANIMOV
Title or Position: OWNER
Credential: DDS
Phone: 917-604-6925