Provider Demographics
NPI:1578883419
Name:IVANOV, ANDREY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREY
Middle Name:
Last Name:IVANOV
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 1:803 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1114
Mailing Address - Country:US
Mailing Address - Phone:732-636-7624
Mailing Address - Fax:
Practice Address - Street 1:575 FULTON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5309
Practice Address - Country:US
Practice Address - Phone:718-596-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0497341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice