Provider Demographics
NPI:1417488651
Name:BANCROFT, KAITLIN ELIZABETH MARTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KAITLIN
Middle Name:ELIZABETH MARTIN
Last Name:BANCROFT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KAITLIN
Other - Middle Name:ELIZABETH
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:63 DRAPER RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-2131
Mailing Address - Country:US
Mailing Address - Phone:413-374-4566
Mailing Address - Fax:
Practice Address - Street 1:38 OXFORD RD
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1530
Practice Address - Country:US
Practice Address - Phone:413-374-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS42646050122300000X
MADN18584821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA00000Medicaid