Provider Demographics
NPI:1336327782
Name:ITSKOVICH, DMITRIY (DDS)
Entity Type:Individual
Prefix:DR
First Name:DMITRIY
Middle Name:
Last Name:ITSKOVICH
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 1:481 N FREDERICK AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2470
Mailing Address - Country:US
Mailing Address - Phone:301-926-1407
Mailing Address - Fax:301-926-9035
Practice Address - Street 1:481 N FREDERICK AVE STE 104
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2470
Practice Address - Country:US
Practice Address - Phone:301-926-1407
Practice Address - Fax:301-926-9035
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist