Provider Demographics
NPI:1902931686
Name:STANISLAV KOVTUN DMD, PC
Entity Type:Organization
Organization Name:STANISLAV KOVTUN DMD, PC
Other - Org Name:ALPHA PLUS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVTUN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-277-6360
Mailing Address - Street 1:185 HARVARD STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5013
Mailing Address - Country:US
Mailing Address - Phone:617-277-6360
Mailing Address - Fax:617-277-7333
Practice Address - Street 1:185 HARVARD STREET
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5013
Practice Address - Country:US
Practice Address - Phone:617-274-8494
Practice Address - Fax:617-277-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0278238Medicaid