Provider Demographics
NPI:1316936479
Name:KONDRATYEVA, NATALYA (DDS)
Entity type:Individual
Prefix:DR
First Name:NATALYA
Middle Name:
Last Name:KONDRATYEVA
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 1:352 SECOND STREET PIKE #396
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-2425
Mailing Address - Country:US
Mailing Address - Phone:215-745-5734
Mailing Address - Fax:
Practice Address - Street 1:433 MARKET ST STE 102
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08102
Practice Address - Country:US
Practice Address - Phone:856-963-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029186L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014964000001OtherMEDICAL ASSISTANCE
NJ0617415Medicaid
PA0001749OtherHEALTH PARTNERS