Provider Demographics
NPI:1093987018
Name:RAFAILOV, SALAMON
Entity type:Individual
Prefix:DR
First Name:SALAMON
Middle Name:
Last Name:RAFAILOV
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18706 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1705
Mailing Address - Country:US
Mailing Address - Phone:178-654-4329
Mailing Address - Fax:
Practice Address - Street 1:3071 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5122
Practice Address - Country:US
Practice Address - Phone:718-736-0123
Practice Address - Fax:718-743-0425
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02366600122300000X
NY053916122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist