Provider Demographics
NPI:1740673151
Name:ZHIVAGO, PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:ZHIVAGO
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 1:19 RYERSON PL
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2505
Mailing Address - Country:US
Mailing Address - Phone:646-318-0510
Mailing Address - Fax:
Practice Address - Street 1:44 E 67TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6135
Practice Address - Country:US
Practice Address - Phone:212-988-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057240-11223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics