Provider Demographics
NPI:1689359184
Name:DIBIASIO, KAYLA KATHLEEN (DMD)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:KATHLEEN
Last Name:DIBIASIO
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 1:74 BEAVER BROOK RD
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01460-1225
Mailing Address - Country:US
Mailing Address - Phone:978-732-4778
Mailing Address - Fax:
Practice Address - Street 1:18 NORTH RD STE 9
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-2771
Practice Address - Country:US
Practice Address - Phone:978-256-2561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859796122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist