Provider Demographics
NPI:1164692687
Name:KOMAROVSKAYA, INNA O (DMD)
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:O
Last Name:KOMAROVSKAYA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1212 RIVER ST
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-2906
Practice Address - Country:US
Practice Address - Phone:617-361-4833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice