Provider Demographics
NPI:1336763614
Name:KOLONTAROV, AVRAHAM
Entity Type:Individual
Prefix:
First Name:AVRAHAM
Middle Name:
Last Name:KOLONTAROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8410 126TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2206
Mailing Address - Country:US
Mailing Address - Phone:347-430-7582
Mailing Address - Fax:
Practice Address - Street 1:1502 E 14TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7283
Practice Address - Country:US
Practice Address - Phone:718-709-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0619261223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health