Provider Demographics
NPI:1033264866
Name:KONICOV, DAVID IRA (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:IRA
Last Name:KONICOV
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 1:189 GOVERNOR ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3124
Mailing Address - Country:US
Mailing Address - Phone:401-421-1457
Mailing Address - Fax:
Practice Address - Street 1:189 GOVERNOR ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3124
Practice Address - Country:US
Practice Address - Phone:401-421-1457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDK01000Medicaid
RI1907OtherRI LICENSE