Provider Demographics
NPI:1891438412
Name:SIROTENKO, NICHOLAS ALEXANDER
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:SIROTENKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 ELMWOOD AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1655 ELMWOOD AVE STE 105
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3426
Practice Address - Country:US
Practice Address - Phone:585-427-8620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0641771223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry