Provider Demographics
NPI:1265461107
Name:PEYSAKHOV, EDUARD (DMD)
Entity Type:Individual
Prefix:
First Name:EDUARD
Middle Name:
Last Name:PEYSAKHOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:CROSS POINT
Other - Middle Name:
Other - Last Name:FAMILY DENTAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DBA
Mailing Address - Street 1:850 CHELMSFORD ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-5149
Mailing Address - Country:US
Mailing Address - Phone:978-459-6467
Mailing Address - Fax:978-458-1857
Practice Address - Street 1:850 CHELMSFORD ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-5149
Practice Address - Country:US
Practice Address - Phone:978-459-6467
Practice Address - Fax:978-458-1857
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA043554547OtherTIN