Provider Demographics
NPI:1134100936
Name:AVDEYCHIK, TATYANA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:TATYANA
Middle Name:
Last Name:AVDEYCHIK
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 1:1810 JEROME AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3621
Mailing Address - Country:US
Mailing Address - Phone:718-646-0900
Mailing Address - Fax:718-769-9723
Practice Address - Street 1:1810 JEROME AVE FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3621
Practice Address - Country:US
Practice Address - Phone:718-646-0900
Practice Address - Fax:718-769-9723
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044239122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01376829Medicaid