Provider Demographics
NPI:1255604203
Name:LUTZKY, MARKO WSEWOLOD (DDS)
Entity type:Individual
Prefix:
First Name:MARKO
Middle Name:WSEWOLOD
Last Name:LUTZKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39-26 65TH STREET
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3638
Mailing Address - Country:US
Mailing Address - Phone:212-697-8178
Mailing Address - Fax:
Practice Address - Street 1:30 EAST 40TH STREET
Practice Address - Street 2:SUITE 706
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-697-8178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037691-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist