Provider Demographics
NPI:1417026584
Name:MY DENTIST
Entity Type:Organization
Organization Name:MY DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOZADA
Authorized Official - Suffix:I
Authorized Official - Credentials:DDS, DMD
Authorized Official - Phone:617-566-1524
Mailing Address - Street 1:1297 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5242
Mailing Address - Country:US
Mailing Address - Phone:617-566-1524
Mailing Address - Fax:617-566-1514
Practice Address - Street 1:1297 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5242
Practice Address - Country:US
Practice Address - Phone:617-566-1524
Practice Address - Fax:617-566-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195691223E0200X
MA204301223G0001X, 1223P0700X
MA191771223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty