Provider Demographics
NPI:1912344904
Name:BELOTSERKOVSKY, DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:BELOTSERKOVSKY
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 1:10 SAINT JOHNS MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5201
Mailing Address - Country:US
Mailing Address - Phone:904-770-2686
Mailing Address - Fax:
Practice Address - Street 1:10 SAINT JOHNS MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5201
Practice Address - Country:US
Practice Address - Phone:904-770-2686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN217571223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice