Provider Demographics
NPI:1790096584
Name:MIKHLY, JACQUELINE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:MIKHLY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:SIMANOVSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:475 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3436
Mailing Address - Country:US
Mailing Address - Phone:917-974-8445
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0559821223P0221X
NJ22DI025293001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry