Provider Demographics
NPI:1710102975
Name:KOROBOVA, ELLA (DDS)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:KOROBOVA
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 1:5A ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1109
Mailing Address - Country:US
Mailing Address - Phone:201-339-7275
Mailing Address - Fax:201-339-0801
Practice Address - Street 1:473 BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3697
Practice Address - Country:US
Practice Address - Phone:201-339-7275
Practice Address - Fax:201-339-0801
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI022011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9052909Medicaid