Provider Demographics
NPI:1952622169
Name:KONTAX, CARLA IRENE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:IRENE
Last Name:KONTAX
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 1:386 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2215
Mailing Address - Country:US
Mailing Address - Phone:617-464-5825
Mailing Address - Fax:617-464-5828
Practice Address - Street 1:386 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127
Practice Address - Country:US
Practice Address - Phone:617-464-5825
Practice Address - Fax:617-464-5828
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18999122300000X
MADN1855460122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist