Provider Demographics
NPI:1922462100
Name:STANISLAV KOVTUN, DMD PC
Entity Type:Organization
Organization Name:STANISLAV KOVTUN, DMD PC
Other - Org Name:ALPHA PLUS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STANISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVTUN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-277-6360
Mailing Address - Street 1:185 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446
Mailing Address - Country:US
Mailing Address - Phone:617-277-6360
Mailing Address - Fax:617-277-7333
Practice Address - Street 1:185 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:617-274-8494
Practice Address - Fax:617-277-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110097248AMedicaid