Provider Demographics
NPI:1336255439
Name:VAKSMAN, INNA (DDS)
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:VAKSMAN
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 1:5647 MYRTLE AVENUE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-4744
Mailing Address - Country:US
Mailing Address - Phone:718-417-6300
Mailing Address - Fax:718-417-3535
Practice Address - Street 1:5647 MYRTLE AVENUE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4744
Practice Address - Country:US
Practice Address - Phone:718-417-6300
Practice Address - Fax:718-417-3535
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045227122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01512830Medicaid