Provider Demographics
NPI:1770930455
Name:KOMNATNAYA, ANNA (DMD)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:KOMNATNAYA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 ROCKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:MA
Mailing Address - Zip Code:01747-1451
Mailing Address - Country:US
Mailing Address - Phone:508-381-9494
Mailing Address - Fax:
Practice Address - Street 1:245 FIRST ST STE 18
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02142-1292
Practice Address - Country:US
Practice Address - Phone:888-833-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program