Provider Demographics
NPI:1205409349
Name:STSIATSEVICH, SVIATLANA (DDS)
Entity Type:Individual
Prefix:
First Name:SVIATLANA
Middle Name:
Last Name:STSIATSEVICH
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 1:515 N WOOD AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-4173
Mailing Address - Country:US
Mailing Address - Phone:908-486-5000
Mailing Address - Fax:
Practice Address - Street 1:515 N WOOD AVE STE 102
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4173
Practice Address - Country:US
Practice Address - Phone:908-486-5000
Practice Address - Fax:908-486-5006
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI028514001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice