Provider Demographics
NPI:1871819607
Name:TAKHALOVA, LARISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:
Last Name:TAKHALOVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3512
Mailing Address - Country:US
Mailing Address - Phone:518-512-3001
Mailing Address - Fax:
Practice Address - Street 1:6932 FLEET ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5148
Practice Address - Country:US
Practice Address - Phone:718-670-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2017-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist