Provider Demographics
NPI:1093796963
Name:PONOMAREVA, SVETLANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SVETLANA
Middle Name:
Last Name:PONOMAREVA
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 1:3627 BRODWAY
Mailing Address - Street 2:
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:212-234-2300
Mailing Address - Fax:212-234-2301
Practice Address - Street 1:3627 BRODWAY
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10031
Practice Address - Country:US
Practice Address - Phone:212-234-2300
Practice Address - Fax:212-234-2301
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02224179Medicaid