Provider Demographics
NPI:1821147372
Name:FATTAKHOV, RUBEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUBEN
Middle Name:
Last Name:FATTAKHOV
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 1:6282 SAUNDERS ST APT 5I
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1554
Mailing Address - Country:US
Mailing Address - Phone:718-459-0915
Mailing Address - Fax:
Practice Address - Street 1:105-10 62 RD
Practice Address - Street 2:APT 1F
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-760-8400
Practice Address - Fax:718-760-8114
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0468471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01709737Medicaid