Provider Demographics
NPI:1780864488
Name:WIKTORZAK, KONRAD RADOSLAW (DDS)
Entity Type:Individual
Prefix:DR
First Name:KONRAD
Middle Name:RADOSLAW
Last Name:WIKTORZAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CYGNET RD
Mailing Address - Street 2:
Mailing Address - City:CONGERS
Mailing Address - State:NY
Mailing Address - Zip Code:10920-1789
Mailing Address - Country:US
Mailing Address - Phone:845-893-2509
Mailing Address - Fax:
Practice Address - Street 1:510 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5305
Practice Address - Country:US
Practice Address - Phone:646-321-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0537231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice