Provider Demographics
NPI:1609498948
Name:DONOVAN, CALLAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:CALLAN
Middle Name:
Last Name:DONOVAN
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 1:501 CONGRESS ST APT 720
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-2922
Mailing Address - Country:US
Mailing Address - Phone:207-712-5151
Mailing Address - Fax:
Practice Address - Street 1:77 BROAD ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-5003
Practice Address - Country:US
Practice Address - Phone:781-490-9518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-09
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18593301223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program