Provider Demographics
NPI:1437114170
Name:KHANMAMEDOV, ALTAY (DDS)
Entity type:Individual
Prefix:
First Name:ALTAY
Middle Name:
Last Name:KHANMAMEDOV
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 1:801 WEST 181 ST
Mailing Address - Street 2:#26
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 W 57TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3158
Practice Address - Country:US
Practice Address - Phone:917-338-6358
Practice Address - Fax:917-470-9486
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02559039Medicare ID - Type Unspecified