MEDICARE: DR. YELENA VINOGRADOV DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS030310-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164593794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YELENA VINOGRADOV DMD

Provider Business Mailing Address
First Line	:	401 COMMERCE DR
Second Line	:	SUITE 108
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-2714
Country	:	US
Telephone Number	:	215-342-5750
Fax Number	:	215-646-6166

Provider Business Practice Location Address
First Line	:	8539 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-1203
Country	:	US
Telephone Number	:	215-342-5750
Fax Number	:	215-646-6166

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	02/15/2013

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