Provider Demographics
NPI:1144842758
Name:DAVIDYAN, IDAN YAAKOV (DMD)
Entity type:Individual
Prefix:DR
First Name:IDAN
Middle Name:YAAKOV
Last Name:DAVIDYAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ELM TOP LN
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4665
Mailing Address - Country:US
Mailing Address - Phone:978-778-4256
Mailing Address - Fax:
Practice Address - Street 1:9 BROADWAY
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4417
Practice Address - Country:US
Practice Address - Phone:978-922-0778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858650122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist