Provider Demographics
NPI:1497744544
Name:VASSERMAN, VADIM (DDS)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:VASSERMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 PELHAM PKWY S
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1013
Mailing Address - Country:US
Mailing Address - Phone:718-822-6896
Mailing Address - Fax:718-597-8462
Practice Address - Street 1:1144 PELHAM PKWY S
Practice Address - Street 2:#A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1012
Practice Address - Country:US
Practice Address - Phone:718-822-6896
Practice Address - Fax:718-597-8462
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0479191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02059103Medicaid