Provider Demographics
NPI:1104969583
Name:KOSTENKO, VALERIY (D M D)
Entity type:Individual
Prefix:DR
First Name:VALERIY
Middle Name:
Last Name:KOSTENKO
Suffix:
Gender:M
Credentials:D M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1115
Mailing Address - Country:US
Mailing Address - Phone:781-581-1411
Mailing Address - Fax:781-581-1433
Practice Address - Street 1:74 MARKET ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1115
Practice Address - Country:US
Practice Address - Phone:781-581-1411
Practice Address - Fax:781-581-1433
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0281956Medicaid