Provider Demographics
NPI:1578718045
Name:DEMENTYEVA, OLENA (DOM)
Entity Type:Individual
Prefix:MRS
First Name:OLENA
Middle Name:
Last Name:DEMENTYEVA
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 PENNSYLVANIA AVE
Mailing Address - Street 2:APT # 2
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-7714
Mailing Address - Country:US
Mailing Address - Phone:786-999-4499
Mailing Address - Fax:
Practice Address - Street 1:960 W 41ST ST
Practice Address - Street 2:SUITE 116
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-3326
Practice Address - Country:US
Practice Address - Phone:786-999-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2493171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist