Provider Demographics
NPI:1023008786
Name:TKACHUK, ANZHELA (DDS)
Entity Type:Individual
Prefix:
First Name:ANZHELA
Middle Name:
Last Name:TKACHUK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 SAND LN
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4543
Mailing Address - Country:US
Mailing Address - Phone:718-273-5006
Mailing Address - Fax:718-273-2778
Practice Address - Street 1:128 SAND LN
Practice Address - Street 2:1ST FLOOR
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-4543
Practice Address - Country:US
Practice Address - Phone:718-273-5006
Practice Address - Fax:718-273-2778
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0506791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice