Provider Demographics
NPI:1154447258
Name:NYKOLAYCHUCK, IVANNA
Entity type:Individual
Prefix:DR
First Name:IVANNA
Middle Name:
Last Name:NYKOLAYCHUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7244 HILLSIDE AVE
Mailing Address - Street 2:APT. #403
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-2353
Mailing Address - Country:US
Mailing Address - Phone:323-851-2423
Mailing Address - Fax:
Practice Address - Street 1:514 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3723
Practice Address - Country:US
Practice Address - Phone:323-851-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA483461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice