MEDICARE: DR. OLEG TABAK D.D.S.

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	22DI02295200	NJ
2	1223G0001X	General Practice Dentistry	048956-1	NY

General Provider Information

NPI Number	:	1265461420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLEG TABAK D.D.S.

Provider Business Mailing Address
First Line	:	500 RIVER AVE
Second Line	:	SUITE 240
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-4738
Country	:	US
Telephone Number	:	732-364-5505
Fax Number	:	732-364-5595

Provider Business Practice Location Address
First Line	:	500 RIVER AVE
Second Line	:	SUITE 240
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-4738
Country	:	US
Telephone Number	:	732-364-5505
Fax Number	:	732-364-5595

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

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	05/05/2010

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