Provider Demographics
NPI:1619648003
Name:VDOVETS, DINA
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:VDOVETS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 OCONNERS LN
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7021
Mailing Address - Country:US
Mailing Address - Phone:917-254-0578
Mailing Address - Fax:
Practice Address - Street 1:2102 AVENUE Z STE 304
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2812
Practice Address - Country:US
Practice Address - Phone:347-921-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1508222211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist