Healthcare Provider Details

I. General information

NPI: 1265580237
Provider Name (Legal Business Name): KATHRYN POLYAKOV DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 CONCORD ST STE 1
FRAMINGHAM MA
01702-8066
US

IV. Provider business mailing address

615 CONCORD ST STE 1
FRAMINGHAM MA
01702-8066
US

V. Phone/Fax

Practice location:
  • Phone: 508-872-0045
  • Fax: 508-281-1406
Mailing address:
  • Phone: 508-872-0045
  • Fax: 508-281-1406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number19569
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20584
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13973
License Number StateMA

VIII. Authorized Official

Name: KATHRYN ALEXANDRA POLYAKOV
Title or Position: DENTIST/OWNER
Credential:
Phone: 508-872-0045