Provider Demographics
NPI:1538494109
Name:FATAKHOV, ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:FATAKHOV
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 1:9936 62ND DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1938
Mailing Address - Country:US
Mailing Address - Phone:917-291-4232
Mailing Address - Fax:718-275-7126
Practice Address - Street 1:3118 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3909
Practice Address - Country:US
Practice Address - Phone:718-728-7812
Practice Address - Fax:718-728-1705
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0544341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice