Healthcare Provider Details

I. General information

NPI: 1336255439
Provider Name (Legal Business Name): INNA VAKSMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5647 MYRTLE AVENUE 1ST FLOOR
RIDGEWOOD NY
11385-4744
US

IV. Provider business mailing address

5647 MYRTLE AVENUE 1ST FLOOR
RIDGEWOOD NY
11385-4744
US

V. Phone/Fax

Practice location:
  • Phone: 718-417-6300
  • Fax: 718-417-3535
Mailing address:
  • Phone: 718-417-6300
  • Fax: 718-417-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number045227
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: