Provider Demographics
NPI:1639880677
Name:RENAISSANCE PLASTIC SURGERY PLLC
Entity Type:Organization
Organization Name:RENAISSANCE PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMANTOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-387-7834
Mailing Address - Street 1:PO BOX 220424
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11022-0424
Mailing Address - Country:US
Mailing Address - Phone:917-387-7834
Mailing Address - Fax:
Practice Address - Street 1:590 5TH AVE FL 11
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4748
Practice Address - Country:US
Practice Address - Phone:917-387-7834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty