Provider Demographics
NPI:1679860852
Name:SITKOVETSKIY, MIKHAIL (MIKHAIL SITKOVETSKIY)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:SITKOVETSKIY
Suffix:
Gender:M
Credentials:MIKHAIL SITKOVETSKIY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2180 MACARTHUR RD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-4535
Practice Address - Country:US
Practice Address - Phone:610-437-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038816122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist