Provider Demographics
NPI:1336205699
Name:RADIVONYK, EDWARD STEPHEN JR (DMD)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:STEPHEN
Last Name:RADIVONYK
Suffix:JR
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 1:637 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-3107
Mailing Address - Country:US
Mailing Address - Phone:978-342-2222
Mailing Address - Fax:978-342-1292
Practice Address - Street 1:637 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-3107
Practice Address - Country:US
Practice Address - Phone:978-342-2222
Practice Address - Fax:978-342-1292
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN162211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0269441Medicaid