Provider Demographics
NPI:1295956357
Name:FUNDAMINSKY, GENNADY M (DDS)
Entity type:Individual
Prefix:DR
First Name:GENNADY
Middle Name:M
Last Name:FUNDAMINSKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:GENNADY
Other - Middle Name:M
Other - Last Name:FUNDAMINSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:9615 BRIGHTON WAY
Mailing Address - Street 2:216
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210
Mailing Address - Country:US
Mailing Address - Phone:310-278-0814
Mailing Address - Fax:310-278-3487
Practice Address - Street 1:9615 BRIGHTON WAY
Practice Address - Street 2:216
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210
Practice Address - Country:US
Practice Address - Phone:310-278-0814
Practice Address - Fax:310-278-3487
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery