Provider Demographics
NPI:1285160945
Name:KHAZANOVICH, SOFIYA (DDS)
Entity type:Individual
Prefix:
First Name:SOFIYA
Middle Name:
Last Name:KHAZANOVICH
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 1:235 BAY 43RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-6701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 BAY 43RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-6701
Practice Address - Country:US
Practice Address - Phone:718-887-6798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0598181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice