Provider Demographics
NPI:1508919820
Name:GORBUNOV, DMITRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:
Last Name:GORBUNOV
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 1:9123 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5531
Mailing Address - Country:US
Mailing Address - Phone:718-943-8680
Mailing Address - Fax:718-943-8683
Practice Address - Street 1:9123 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5531
Practice Address - Country:US
Practice Address - Phone:718-943-8680
Practice Address - Fax:718-943-8683
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043066-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9178486OtherDORAL
NY01214108Medicaid