Provider Demographics
NPI:1063555340
Name:ZHIVULKO-KHAVIN, ANNA (DDS)
Entity type:Individual
Prefix:MS
First Name:ANNA
Middle Name:
Last Name:ZHIVULKO-KHAVIN
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 1:3550 81ST ST
Mailing Address - Street 2:SUITE 1G
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5068
Mailing Address - Country:US
Mailing Address - Phone:718-565-2461
Mailing Address - Fax:718-565-3153
Practice Address - Street 1:24026 70TH AVE
Practice Address - Street 2:
Practice Address - City:DOUGLASTON
Practice Address - State:NY
Practice Address - Zip Code:11362-1948
Practice Address - Country:US
Practice Address - Phone:718-428-4926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0383321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00861734Medicaid