Provider Demographics
NPI:1255413738
Name:KHRAKOVSKY, VADIM (DDS)
Entity type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:KHRAKOVSKY
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 1:2791 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-4624
Mailing Address - Country:US
Mailing Address - Phone:718-449-5559
Mailing Address - Fax:
Practice Address - Street 1:2791 W 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-4624
Practice Address - Country:US
Practice Address - Phone:718-449-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0443431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01360109Medicaid
NY5N3301OtherDELTA
NYC1673OtherBCBS
NYBK3424962OtherDEA REG.