Provider Demographics
NPI:1952531931
Name:PTAK-YENCHMAN, NICOLE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:PTAK-YENCHMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:PTAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2200 NORTHERN BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548
Mailing Address - Country:US
Mailing Address - Phone:516-621-6100
Mailing Address - Fax:516-621-6101
Practice Address - Street 1:2200 NORTHERN BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548
Practice Address - Country:US
Practice Address - Phone:516-621-6100
Practice Address - Fax:516-621-6101
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0552731122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist