Provider Demographics
NPI:1760510044
Name:STABNIKOV, BORIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:STABNIKOV
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 1:341 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-1813
Mailing Address - Country:US
Mailing Address - Phone:401-648-5570
Mailing Address - Fax:
Practice Address - Street 1:150 SOCIAL ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3133
Practice Address - Country:US
Practice Address - Phone:401-597-5077
Practice Address - Fax:401-597-5077
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN026191223G0001X
MA192141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0280283OtherMASS HEALTH
RI8055-2OtherBLUE CROSS BLUE SHIELD
MA0280283OtherMASS HEALTH