Provider Demographics
NPI:1376116723
Name:VOLCHONOK, MICHELE LAUREN
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LAUREN
Last Name:VOLCHONOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2815
Mailing Address - Country:US
Mailing Address - Phone:856-524-1607
Mailing Address - Fax:
Practice Address - Street 1:4 DEARFIELD DR STE 104
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5351
Practice Address - Country:US
Practice Address - Phone:203-293-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0431861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice