Healthcare Provider Details

I. General information

NPI: 1235330770
Provider Name (Legal Business Name): ALEX KENTSIS MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 BROOKLINE AVE
BOSTON MA
02215-5418
US

IV. Provider business mailing address

450 BROOKLINE AVE
BOSTON MA
02215-5418
US

V. Phone/Fax

Practice location:
  • Phone: 617-632-4130
  • Fax: 617-632-4410
Mailing address:
  • Phone: 617-632-4130
  • Fax: 617-632-4410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number228425
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: