Provider Demographics
NPI:1912890500
Name:IVANOVA, VALERIIA
Entity type:Individual
Prefix:
First Name:VALERIIA
Middle Name:
Last Name:IVANOVA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W END AVE APT 5W
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4884
Mailing Address - Country:US
Mailing Address - Phone:518-776-0072
Mailing Address - Fax:
Practice Address - Street 1:515 N WOOD AVE STE 102
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4173
Practice Address - Country:US
Practice Address - Phone:908-743-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI030913001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice