Provider Demographics
NPI:1518457969
Name:BAGAEVA, EKATERINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:EKATERINA
Middle Name:
Last Name:BAGAEVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8828 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7926
Mailing Address - Country:US
Mailing Address - Phone:718-503-1406
Mailing Address - Fax:
Practice Address - Street 1:500 SOUTH ST W
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5342
Practice Address - Country:US
Practice Address - Phone:718-503-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
MADN18584001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program