Provider Demographics
NPI:1073511937
Name:TABAK, ANATOLY (DDS)
Entity type:Individual
Prefix:DR
First Name:ANATOLY
Middle Name:
Last Name:TABAK
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 1:3130 BRIGHTON 6TH ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6954
Mailing Address - Country:US
Mailing Address - Phone:718-648-2067
Mailing Address - Fax:718-648-2147
Practice Address - Street 1:3130 BRIGHTON 6TH ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6954
Practice Address - Country:US
Practice Address - Phone:718-648-2067
Practice Address - Fax:718-648-2147
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0449541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01437594Medicaid