Provider Demographics
NPI:1053711192
Name:KOROLEVSKY, EGER (DDS)
Entity type:Individual
Prefix:
First Name:EGER
Middle Name:
Last Name:KOROLEVSKY
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 1:2350 PROFESSIONAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2350 PROFESSIONAL DR STE 300
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7747
Practice Address - Country:US
Practice Address - Phone:916-961-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA639221223E0200X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223E0200XDental ProvidersDentistEndodontics