Provider Demographics
NPI:1346733235
Name:KANDINOV, ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:KANDINOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DORCHESTER AVE UNIT 51805
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02205-7037
Mailing Address - Country:US
Mailing Address - Phone:248-225-9028
Mailing Address - Fax:
Practice Address - Street 1:25 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02205-0002
Practice Address - Country:US
Practice Address - Phone:248-225-9028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857994122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110136568AMedicaid