Provider Demographics
NPI:1316065253
Name:ORLOV, SERGE (DMD)
Entity type:Individual
Prefix:DR
First Name:SERGE
Middle Name:
Last Name:ORLOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4403
Mailing Address - Country:US
Mailing Address - Phone:617-924-9993
Mailing Address - Fax:617-924-6860
Practice Address - Street 1:21 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472
Practice Address - Country:US
Practice Address - Phone:617-924-9993
Practice Address - Fax:617-924-6860
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0202240Medicaid