Provider Demographics
NPI:1184883696
Name:POLYAKOV, KATHRYN ALEXANDRA (DMD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ALEXANDRA
Last Name:POLYAKOV
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 1:615 CONCORD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-8066
Mailing Address - Country:US
Mailing Address - Phone:508-872-0045
Mailing Address - Fax:508-281-1406
Practice Address - Street 1:615 CONCORD ST STE 1
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8066
Practice Address - Country:US
Practice Address - Phone:508-872-0045
Practice Address - Fax:508-281-1406
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice