Provider Demographics
NPI:1013010529
Name:YERMOLENKO, ALEXANDER (DDS)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:YERMOLENKO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205
Mailing Address - Country:US
Mailing Address - Phone:908-352-2207
Mailing Address - Fax:908-352-2208
Practice Address - Street 1:1219 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205
Practice Address - Country:US
Practice Address - Phone:908-352-2207
Practice Address - Fax:908-352-2208
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D101983800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7280505Medicaid