Provider Demographics
NPI:1992842678
Name:SIMONOVSKIY, GENNADIY
Entity Type:Individual
Prefix:
First Name:GENNADIY
Middle Name:
Last Name:SIMONOVSKIY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 AVENUE J
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-3669
Mailing Address - Country:US
Mailing Address - Phone:718-513-3520
Mailing Address - Fax:718-252-5070
Practice Address - Street 1:1203 AVENUE J
Practice Address - Street 2:SUITE 4A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-3669
Practice Address - Country:US
Practice Address - Phone:718-513-3520
Practice Address - Fax:718-252-5070
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist