Provider Demographics
NPI:1619180650
Name:PODOLSKY, MAXIM ALEXANDER (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAXIM
Middle Name:ALEXANDER
Last Name:PODOLSKY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 67TH AVE
Mailing Address - Street 2:#14V
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4967
Mailing Address - Country:US
Mailing Address - Phone:917-204-5189
Mailing Address - Fax:
Practice Address - Street 1:2272 HENDRICKSON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5131
Practice Address - Country:US
Practice Address - Phone:718-253-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0517731223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics