Provider Demographics
NPI:1306811492
Name:POTEPALOV, VLADIMIR ALEXANDER (DDS)
Entity type:Individual
Prefix:DR
First Name:VLADIMIR
Middle Name:ALEXANDER
Last Name:POTEPALOV
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 1:74 ROUTE 9
Mailing Address - Street 2:UNIT C
Mailing Address - City:ENGLISHTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-9209
Mailing Address - Country:US
Mailing Address - Phone:732-972-7770
Mailing Address - Fax:732-972-7705
Practice Address - Street 1:74 ROUTE 9
Practice Address - Street 2:UNIT C
Practice Address - City:ENGLISHTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07726-9209
Practice Address - Country:US
Practice Address - Phone:732-972-7770
Practice Address - Fax:732-972-7705
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022840001223G0001X
NY0513681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0071331Medicaid
NY051368Medicaid