Provider Demographics
NPI:1659440766
Name:GONCHARUK, IRINA
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:GONCHARUK
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 1:8405 BAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-3359
Mailing Address - Country:US
Mailing Address - Phone:718-331-6100
Mailing Address - Fax:718-331-1723
Practice Address - Street 1:8405 BAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-3359
Practice Address - Country:US
Practice Address - Phone:718-331-6100
Practice Address - Fax:718-331-1723
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0499091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02276680Medicaid