Healthcare Provider Details

I. General information

NPI: 1083282883
Provider Name (Legal Business Name): ALEKSANDR KITAYGORODSKIY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S 17TH ST STE 1206
PHILADELPHIA PA
19103-6212
US

IV. Provider business mailing address

255 S 17TH ST STE 1206
PHILADELPHIA PA
19103-6212
US

V. Phone/Fax

Practice location:
  • Phone: 215-545-5592
  • Fax:
Mailing address:
  • Phone: 215-545-5592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS044224
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: