Provider Demographics
NPI:1811046741
Name:FATTAKHOV, EZRO (DDS)
Entity type:Individual
Prefix:DR
First Name:EZRO
Middle Name:
Last Name:FATTAKHOV
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 1:9926 64TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2646
Mailing Address - Country:US
Mailing Address - Phone:718-830-9091
Mailing Address - Fax:
Practice Address - Street 1:10510 62ND RD
Practice Address - Street 2:APT 1F
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1137
Practice Address - Country:US
Practice Address - Phone:718-760-8400
Practice Address - Fax:718-760-8114
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0468461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01773835Medicaid