Provider Demographics
NPI:1760043079
Name:KRYZHANOVSKIY, RODION
Entity Type:Individual
Prefix:
First Name:RODION
Middle Name:
Last Name:KRYZHANOVSKIY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4173 IMPERIAL CLUB LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8648
Mailing Address - Country:US
Mailing Address - Phone:646-577-7584
Mailing Address - Fax:
Practice Address - Street 1:956 S MILITARY TRL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-3910
Practice Address - Country:US
Practice Address - Phone:561-359-6482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014165831223G0001X
FLDN242451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice