Provider Demographics
NPI:1629290358
Name:KUZNETSOV, MARINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:KUZNETSOV
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E 15TH ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3531
Mailing Address - Country:US
Mailing Address - Phone:212-475-7947
Mailing Address - Fax:212-475-7952
Practice Address - Street 1:145 E 15TH ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3531
Practice Address - Country:US
Practice Address - Phone:212-475-7947
Practice Address - Fax:212-475-7952
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0521161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02698924Medicaid