Provider Demographics
NPI:1780172379
Name:HERON, YELIZAVETA LUCHKOVSKA (DDS)
Entity type:Individual
Prefix:
First Name:YELIZAVETA
Middle Name:LUCHKOVSKA
Last Name:HERON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:YELIZAVETA
Other - Middle Name:
Other - Last Name:LUCHKOVSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:95-211 WAIMAKUA DR
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-3213
Mailing Address - Country:US
Mailing Address - Phone:831-325-1815
Mailing Address - Fax:
Practice Address - Street 1:86-260 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3128
Practice Address - Country:US
Practice Address - Phone:808-697-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-29
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1040201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program