Provider Demographics
NPI:1225171994
Name:MATOSSIAN, KAREKINE (DMD,MS)
Entity Type:Individual
Prefix:DR
First Name:KAREKINE
Middle Name:
Last Name:MATOSSIAN
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 WAVERLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3207
Mailing Address - Country:US
Mailing Address - Phone:617-923-2330
Mailing Address - Fax:617-923-2325
Practice Address - Street 1:222 WAVERLEY AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3207
Practice Address - Country:US
Practice Address - Phone:617-923-2330
Practice Address - Fax:617-923-2325
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA190361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0279935Medicaid