Basic Information
| Provider Information | |||||||||
| NPI: | 1780172379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERON | ||||||||
| FirstName: | YELIZAVETA | ||||||||
| MiddleName: | LUCHKOVSKA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCHKOVSKA | ||||||||
| OtherFirstName: | YELIZAVETA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 95-211 WAIMAKUA DR | ||||||||
| Address2: | |||||||||
| City: | MILILANI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967893213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313251815 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 86-260 FARRINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967923128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086973496 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2018 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | 104020 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.