Provider Demographics
NPI:1255681847
Name:AGNAIEFF, TANYA (DMD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:AGNAIEFF
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 DITMARS BLVD
Mailing Address - Street 2:APT 230
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1319
Mailing Address - Country:US
Mailing Address - Phone:917-943-0804
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1138
Practice Address - Country:US
Practice Address - Phone:718-918-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ215911390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program