Provider Demographics
NPI:1902881964
Name:TITOV, IGOR (DDS)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:TITOV
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 1:602 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4910
Mailing Address - Country:US
Mailing Address - Phone:718-287-2882
Mailing Address - Fax:718-287-8564
Practice Address - Street 1:602 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-4910
Practice Address - Country:US
Practice Address - Phone:718-287-2882
Practice Address - Fax:718-287-8564
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0489901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02102349Medicaid