Provider Demographics
NPI:1093898488
Name:CHERNOMORDIK, MARK (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:CHERNOMORDIK
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 1:219 WHITMAN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6934
Mailing Address - Country:US
Mailing Address - Phone:718-972-1644
Mailing Address - Fax:
Practice Address - Street 1:401 DITMAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-4919
Practice Address - Country:US
Practice Address - Phone:718-972-1644
Practice Address - Fax:718-871-6368
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0382641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice