Provider Demographics
NPI:1750137980
Name:FOMENKO, ZINAIDA
Entity type:Individual
Prefix:
First Name:ZINAIDA
Middle Name:
Last Name:FOMENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ZINAIDA
Other - Middle Name:ALEKSANDROVNA
Other - Last Name:FOMENKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3134 PALM HARBOUR DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-7636
Mailing Address - Country:US
Mailing Address - Phone:979-709-1506
Mailing Address - Fax:
Practice Address - Street 1:19984 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-6505
Practice Address - Country:US
Practice Address - Phone:832-595-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX40716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program