Provider Demographics
NPI:1588790067
Name:LOWELL FAMILY DENTAL PRACTICE PC
Entity type:Organization
Organization Name:LOWELL FAMILY DENTAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KONSTANTIN
Authorized Official - Middle Name:V
Authorized Official - Last Name:AMIRZADOV
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-458-1179
Mailing Address - Street 1:133 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1808
Mailing Address - Country:US
Mailing Address - Phone:978-458-1179
Mailing Address - Fax:978-805-1415
Practice Address - Street 1:133 MARKET STREET
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1808
Practice Address - Country:US
Practice Address - Phone:978-458-1179
Practice Address - Fax:978-805-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215361223G0001X
MA214441223G0001X
MA181971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9727230Medicaid
MAX11619OtherBLUE CROSS BLUE SHIELD
MA9727230Medicaid