Provider Demographics
NPI:1871673707
Name:TERSHAKOVEC, OSTAP (DDS)
Entity Type:Individual
Prefix:DR
First Name:OSTAP
Middle Name:
Last Name:TERSHAKOVEC
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 1:340 E NORTHFIELD RD
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039
Mailing Address - Country:US
Mailing Address - Phone:973-994-7199
Mailing Address - Fax:
Practice Address - Street 1:340 E NORTHFIELD RD
Practice Address - Street 2:SUITE 1C
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039
Practice Address - Country:US
Practice Address - Phone:973-994-7199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ84961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5066808Medicaid