Provider Demographics
NPI:1174703730
Name:TOLSTUNOV, MARINA (DDS)
Entity type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:
Last Name:TOLSTUNOV
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 1:7031 108TH ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4450
Mailing Address - Country:US
Mailing Address - Phone:718-268-8549
Mailing Address - Fax:
Practice Address - Street 1:7031 108TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4450
Practice Address - Country:US
Practice Address - Phone:718-268-8549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-11
Last Update Date:2007-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01353626Medicaid