=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346733235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAN KANDINOV DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2018
-----------------------------------------------------
Last Update Date | 03/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 DORCHESTER AVE
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02205-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-225-9028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 DORCHESTER AVE UNIT 51805
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02205-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-225-9028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1857994
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------