Provider Demographics
NPI:1356784375
Name:KOBAKOV, MIKHAIL YUREVICH (DMD)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:YUREVICH
Last Name:KOBAKOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:YURY
Other - Last Name:KOBAKOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2 JUNGLE RD
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-5208
Mailing Address - Country:US
Mailing Address - Phone:978-534-8300
Mailing Address - Fax:
Practice Address - Street 1:2 JUNGLE RD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-534-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT118091223S0112X
MADN18578951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery