Provider Demographics
NPI:1184808602
Name:VADIM SKORUPKO DDS A PROFESSIONAL CORP
Entity type:Organization
Organization Name:VADIM SKORUPKO DDS A PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLYAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-266-1117
Mailing Address - Street 1:490 POST ST STE 1528
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-1311
Mailing Address - Country:US
Mailing Address - Phone:415-992-5160
Mailing Address - Fax:
Practice Address - Street 1:490 POST ST STE 1528
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-1311
Practice Address - Country:US
Practice Address - Phone:415-992-5160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty