Provider Demographics
NPI:1538206404
Name:CHEREZOV, OLEG (DDS)
Entity type:Individual
Prefix:DR
First Name:OLEG
Middle Name:
Last Name:CHEREZOV
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 1:45 OCEANA DR E
Mailing Address - Street 2:APT # 2 C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6676
Mailing Address - Country:US
Mailing Address - Phone:718-996-5318
Mailing Address - Fax:718-256-3181
Practice Address - Street 1:2626 E 14TH ST
Practice Address - Street 2:SUIT 206
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3966
Practice Address - Country:US
Practice Address - Phone:718-256-3144
Practice Address - Fax:718-256-3181
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0484721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY043656631OtherTAX ID
NY02052615Medicaid