Provider Demographics
NPI:1528280245
Name:TRAKHTENBERG, ROMAN (DDS)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:TRAKHTENBERG
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 1:520 E 81ST ST
Mailing Address - Street 2:APT 6C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-7095
Mailing Address - Country:US
Mailing Address - Phone:917-715-6456
Mailing Address - Fax:
Practice Address - Street 1:1825 FOSTER AVE STE 1B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1848
Practice Address - Country:US
Practice Address - Phone:718-434-4400
Practice Address - Fax:888-371-1841
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048697122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03047927Medicaid