Provider Demographics
NPI:1003952839
Name:ATLANTIS DENTAL LLC
Entity Type:Organization
Organization Name:ATLANTIS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPOVETSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-270-5050
Mailing Address - Street 1:118 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-8304
Mailing Address - Country:US
Mailing Address - Phone:508-270-5050
Mailing Address - Fax:
Practice Address - Street 1:118 CONCORD ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8304
Practice Address - Country:US
Practice Address - Phone:508-270-5050
Practice Address - Fax:508-270-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA186451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX12129OtherBCBS ID
MAX12129OtherBCBS ID
MA0278238Medicare ID - Type UnspecifiedDOCTOR LIPOVETSKIY ID
MA0208345Medicare ID - Type UnspecifiedDR OFIR ID
MA9752081Medicare ID - Type UnspecifiedMASSHEALTH OFFICE ID