Provider Demographics
NPI:1407266257
Name:KOKILASHVILI, NINA (DMD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:KOKILASHVILI
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 1:109 N 12TH ST STE 607
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249-1002
Mailing Address - Country:US
Mailing Address - Phone:929-300-0702
Mailing Address - Fax:929-300-0706
Practice Address - Street 1:109 N 12TH ST STE 607
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-1002
Practice Address - Country:US
Practice Address - Phone:929-300-0702
Practice Address - Fax:929-300-0706
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY058370-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty