Healthcare Provider Details

I. General information

NPI: 1881184158
Provider Name (Legal Business Name): GREGORY YUNOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2018
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BRYANT AVE STE 2, FLOOR 1
ROSLYN NY
11576
US

IV. Provider business mailing address

451 CLARKSON AVE
BROOKLYN NY
11203-2054
US

V. Phone/Fax

Practice location:
  • Phone: 516-744-6262
  • Fax:
Mailing address:
  • Phone: 718-483-1637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02767800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02767800
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: