Provider Demographics
NPI:1376903955
Name:SHPORTKO, ANDRII (DMD)
Entity Type:Individual
Prefix:
First Name:ANDRII
Middle Name:
Last Name:SHPORTKO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 WALGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-3106
Mailing Address - Country:US
Mailing Address - Phone:847-987-0079
Mailing Address - Fax:
Practice Address - Street 1:145 WALGROVE AVE
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-3106
Practice Address - Country:US
Practice Address - Phone:847-987-0079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0595141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice