Provider Demographics
NPI:1417502725
Name:SULEYMANOV, BORIS
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:SULEYMANOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 N 19TH AVE # UINTC
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2903
Mailing Address - Country:US
Mailing Address - Phone:602-433-0313
Mailing Address - Fax:
Practice Address - Street 1:5225 N 19TH AVE # UINTC
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2903
Practice Address - Country:US
Practice Address - Phone:602-433-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-04
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0110361223G0001X
NY060434-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice