Provider Demographics
NPI:1720238090
Name:TARASENKO, ILLYA ALEX (DMD)
Entity Type:Individual
Prefix:DR
First Name:ILLYA
Middle Name:ALEX
Last Name:TARASENKO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 KANE ST
Mailing Address - Street 2:#4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-5229
Mailing Address - Country:US
Mailing Address - Phone:267-304-4701
Mailing Address - Fax:
Practice Address - Street 1:139 KANE ST
Practice Address - Street 2:#4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-5229
Practice Address - Country:US
Practice Address - Phone:267-304-4701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053958122300000X
PA037413122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist