Provider Demographics
NPI:1497912067
Name:DYAKIV, SOPHIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:
Last Name:DYAKIV
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1502
Practice Address - Country:US
Practice Address - Phone:646-643-1951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022183001223G0001X
NY0495481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02259438Medicaid