Provider Demographics
NPI:1184613416
Name:BLAZHKEVICH, NATALIA (DDS)
Entity type:Individual
Prefix:MRS
First Name:NATALIA
Middle Name:
Last Name:BLAZHKEVICH
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 1:1805 215TH ST
Mailing Address - Street 2:APT 11J
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2155
Mailing Address - Country:US
Mailing Address - Phone:718-649-6677
Mailing Address - Fax:718-272-0291
Practice Address - Street 1:1110 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-9061
Practice Address - Country:US
Practice Address - Phone:718-649-6677
Practice Address - Fax:718-272-0291
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048909122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02108574Medicaid