Provider Demographics
NPI:1275392177
Name:VANINOV, ALLA (RDH)
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:VANINOV
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 BULLARD ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-1007
Mailing Address - Country:US
Mailing Address - Phone:617-543-7535
Mailing Address - Fax:
Practice Address - Street 1:102 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2809
Practice Address - Country:US
Practice Address - Phone:617-304-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist