Provider Demographics
NPI:1598891020
Name:AMIRZADOV, KONSTANTIN V (DMD)
Entity Type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:V
Last Name:AMIRZADOV
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 1:133 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852
Mailing Address - Country:US
Mailing Address - Phone:978-458-1179
Mailing Address - Fax:978-805-1415
Practice Address - Street 1:133 MARKET STREET
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-458-1179
Practice Address - Fax:978-805-1415
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11615OtherBLUE CROSS BLUE SHIELD
MA2752307Medicaid