Provider Demographics
NPI:1750838785
Name:SPIVAK, OLGA S (DMD)
Entity Type:Individual
Prefix:DR
First Name:OLGA
Middle Name:S
Last Name:SPIVAK
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 1:30 SUMMER ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1701
Mailing Address - Country:US
Mailing Address - Phone:917-817-7369
Mailing Address - Fax:
Practice Address - Street 1:551 BOYLSTON ST
Practice Address - Street 2:SUITE 501
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3605
Practice Address - Country:US
Practice Address - Phone:617-536-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist