Provider Demographics
NPI:1750371464
Name:SKUTELSKY, MARINA (DDS)
Entity type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:SKUTELSKY
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 1:9229 QUEENS BLVD
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1056
Mailing Address - Country:US
Mailing Address - Phone:718-268-8225
Mailing Address - Fax:
Practice Address - Street 1:9229 QUEENS BLVD
Practice Address - Street 2:SUITE 1E
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1056
Practice Address - Country:US
Practice Address - Phone:718-268-8225
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0335331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00284006Medicaid