Provider Demographics
NPI:1144492687
Name:KRAVETS, GENNADIY (DMD)
Entity type:Individual
Prefix:
First Name:GENNADIY
Middle Name:
Last Name:KRAVETS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 UNION AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-7467
Mailing Address - Country:US
Mailing Address - Phone:718-388-4613
Mailing Address - Fax:718-388-4613
Practice Address - Street 1:202 UNION AVE
Practice Address - Street 2:SUITE D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7467
Practice Address - Country:US
Practice Address - Phone:718-388-4613
Practice Address - Fax:718-388-4613
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052594-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02721328Medicaid