Provider Demographics
NPI:1164641122
Name:KUZNETSOV, SERGEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SERGEY
Middle Name:
Last Name:KUZNETSOV
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 1:145 E 15TH ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3531
Mailing Address - Country:US
Mailing Address - Phone:212-475-7947
Mailing Address - Fax:212-475-7952
Practice Address - Street 1:65 ORIENTAL BLVD
Practice Address - Street 2:LBB
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4945
Practice Address - Country:US
Practice Address - Phone:718-769-6777
Practice Address - Fax:718-769-6775
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052229-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02698951Medicaid