Provider Demographics
NPI:1285834028
Name:GONCHAROV, OLEG (DDS)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:GONCHAROV
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 1:24 5TH AVE APT 615
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8817
Mailing Address - Country:US
Mailing Address - Phone:646-244-2222
Mailing Address - Fax:
Practice Address - Street 1:2022 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2225
Practice Address - Country:US
Practice Address - Phone:212-987-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050550122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02573971Medicaid