Provider Demographics
NPI:1417107178
Name:KHAYLOMSKY, LENA (DMD)
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:KHAYLOMSKY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LENA
Other - Middle Name:
Other - Last Name:KHAYLOMSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4100 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-6196
Mailing Address - Country:US
Mailing Address - Phone:201-348-1616
Mailing Address - Fax:201-348-4877
Practice Address - Street 1:4100 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-6196
Practice Address - Country:US
Practice Address - Phone:201-348-1616
Practice Address - Fax:201-348-4877
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ224241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0038792Medicaid