Provider Demographics
NPI:1497266852
Name:AVETISYAN, TIGRAN (DMD)
Entity Type:Individual
Prefix:
First Name:TIGRAN
Middle Name:
Last Name:AVETISYAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-2234
Mailing Address - Country:US
Mailing Address - Phone:616-780-4642
Mailing Address - Fax:
Practice Address - Street 1:131 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1723
Practice Address - Country:US
Practice Address - Phone:978-788-9338
Practice Address - Fax:978-225-2591
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18577761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1811901473Medicaid