Provider Demographics
NPI:1457915894
Name:MOGILEVSKY, ROMAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:MOGILEVSKY
Suffix:
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 1:128 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-3201
Mailing Address - Country:US
Mailing Address - Phone:617-669-5588
Mailing Address - Fax:
Practice Address - Street 1:128 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-3201
Practice Address - Country:US
Practice Address - Phone:617-669-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI02819800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program