Provider Demographics
NPI:1083718167
Name:TAGAYEVSKY, SERGEY (DDS)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:TAGAYEVSKY
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 1:99-21 67TH ROAD #1G
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3013
Mailing Address - Country:US
Mailing Address - Phone:718-897-5400
Mailing Address - Fax:718-897-5400
Practice Address - Street 1:99-21 67TH ROAD #1G
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3013
Practice Address - Country:US
Practice Address - Phone:718-897-5400
Practice Address - Fax:718-897-5400
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0448401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01433334Medicaid
66278OtherDHA