Provider Demographics
NPI:1659000859
Name:REZNICHENKO, VLADISLAV ALEKSANDROVICH (DMD)
Entity Type:Individual
Prefix:
First Name:VLADISLAV
Middle Name:ALEKSANDROVICH
Last Name:REZNICHENKO
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 1:2105 CONWAY CIR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8110
Mailing Address - Country:US
Mailing Address - Phone:864-541-9705
Mailing Address - Fax:
Practice Address - Street 1:1505 RED BANK RD
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-4516
Practice Address - Country:US
Practice Address - Phone:843-824-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.102211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice