Provider Demographics
NPI:1417127671
Name:DR.KOSTENKO D.M.D. P.C.
Entity Type:Organization
Organization Name:DR.KOSTENKO D.M.D. P.C.
Other - Org Name:ACE DENTAL ASS.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOSTENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-581-1411
Mailing Address - Street 1:74 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1115
Mailing Address - Country:US
Mailing Address - Phone:781-581-1411
Mailing Address - Fax:781-581-1433
Practice Address - Street 1:74 MARKET ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1115
Practice Address - Country:US
Practice Address - Phone:781-581-1411
Practice Address - Fax:781-581-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty