Provider Demographics
NPI:1588803407
Name:KIGURADZE, KETEVAN (DDS)
Entity Type:Individual
Prefix:
First Name:KETEVAN
Middle Name:
Last Name:KIGURADZE
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 1:106 NOROTON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-5237
Mailing Address - Country:US
Mailing Address - Phone:203-202-7728
Mailing Address - Fax:
Practice Address - Street 1:106 NOROTON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-5237
Practice Address - Country:US
Practice Address - Phone:203-202-7728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009629122300000X, 1223P0221X
NY50 052767122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist