Provider Demographics
NPI:1669516993
Name:YELENA V. GUTNICHENKO, DMD, P.C.
Entity type:Organization
Organization Name:YELENA V. GUTNICHENKO, DMD, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:V
Authorized Official - Last Name:GUTNICHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-899-9530
Mailing Address - Street 1:52 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5317
Mailing Address - Country:US
Mailing Address - Phone:781-899-9530
Mailing Address - Fax:781-736-0977
Practice Address - Street 1:52 ELM ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5317
Practice Address - Country:US
Practice Address - Phone:781-899-9530
Practice Address - Fax:781-736-0977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9732811Medicaid