Provider Demographics
NPI:1265580237
Name:KATHRYN POLYAKOV DMD PC
Entity type:Organization
Organization Name:KATHRYN POLYAKOV DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:POLYAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-872-0045
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205841223G0001X
MA139731223P0300X
MA195691223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty