Provider Demographics
NPI:1164165874
Name:AGABABAYEVA, KAMILLA
Entity Type:Individual
Prefix:
First Name:KAMILLA
Middle Name:
Last Name:AGABABAYEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GREYROCK PL STE 116
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-3113
Mailing Address - Country:US
Mailing Address - Phone:718-218-5505
Mailing Address - Fax:
Practice Address - Street 1:100 GREYROCK PL STE 116
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-3113
Practice Address - Country:US
Practice Address - Phone:203-348-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT137371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice