Provider Demographics
NPI:1598859332
Name:GUTMAN, YELENA (DDS)
Entity type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:GUTMAN
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 1:247 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4317
Mailing Address - Country:US
Mailing Address - Phone:718-368-0900
Mailing Address - Fax:718-368-0107
Practice Address - Street 1:2102 E 24TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4902
Practice Address - Country:US
Practice Address - Phone:718-368-0900
Practice Address - Fax:718-368-0107
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045541122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01651147Medicaid