Provider Demographics
NPI:1992018766
Name:KONOVALOV, ANATOLIY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANATOLIY
Middle Name:
Last Name:KONOVALOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 MERMAID AVE
Mailing Address - Street 2:NYC FAMILY DENTAL CARE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2374
Mailing Address - Country:US
Mailing Address - Phone:718-975-4475
Mailing Address - Fax:
Practice Address - Street 1:3002 MERMAID AVE
Practice Address - Street 2:NYC FAMILY DENTAL CARE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2374
Practice Address - Country:US
Practice Address - Phone:718-975-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist