Provider Demographics
NPI:1407864259
Name:PAVOLOTSKY, KONSTANTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KONSTANTIN
Middle Name:
Last Name:PAVOLOTSKY
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 1:6028 MAYFIELD RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124
Mailing Address - Country:US
Mailing Address - Phone:440-684-9424
Mailing Address - Fax:440-684-0126
Practice Address - Street 1:6028 MAYFIELD RD
Practice Address - Street 2:SUITE 8
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:440-684-9424
Practice Address - Fax:440-684-0126
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30 020384122300000X
IN12009774A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0194178Medicaid