Provider Demographics
NPI:1194088096
Name:GREAT POND DENTAL PC
Entity type:Organization
Organization Name:GREAT POND DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INNA
Authorized Official - Middle Name:O
Authorized Official - Last Name:KOMAROVSKAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-245-1731
Mailing Address - Street 1:202 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1017
Mailing Address - Country:US
Mailing Address - Phone:781-245-1731
Mailing Address - Fax:781-245-2325
Practice Address - Street 1:202 LOWELL ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1017
Practice Address - Country:US
Practice Address - Phone:781-245-1731
Practice Address - Fax:781-245-2325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-17
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN218491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty