Provider Demographics
NPI:1427273267
Name:AGAMOV, ALLA (DMD)
Entity type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:AGAMOV
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 HARTMAN RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 POND ST UNIT 3
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:MA
Practice Address - Zip Code:02067-2044
Practice Address - Country:US
Practice Address - Phone:781-784-8435
Practice Address - Fax:784-784-6598
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20247122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA1084778COtherMSCR