Provider Demographics
NPI:1568196525
Name:KILICHOWSKI, ALEXA DIANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALEXA
Middle Name:DIANE
Last Name:KILICHOWSKI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 HARRISON AVE UNIT 313
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2786
Mailing Address - Country:US
Mailing Address - Phone:813-785-5516
Mailing Address - Fax:
Practice Address - Street 1:124 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1962
Practice Address - Country:US
Practice Address - Phone:617-625-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18594461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice