Provider Demographics
NPI:1386138683
Name:LYAKHOVICH, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:LYAKHOVICH
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 1:28 BLANCHARD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT DESERT
Mailing Address - State:ME
Mailing Address - Zip Code:04660-6215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE CIR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2929
Practice Address - Country:US
Practice Address - Phone:207-479-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000OtherNONE