Provider Demographics
NPI:1699112151
Name:KOVTUN, STANISLAV (DMD)
Entity type:Individual
Prefix:
First Name:STANISLAV
Middle Name:
Last Name:KOVTUN
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 1:25 SHUMAN CIR
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2767
Mailing Address - Country:US
Mailing Address - Phone:781-264-2067
Mailing Address - Fax:
Practice Address - Street 1:185 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5013
Practice Address - Country:US
Practice Address - Phone:617-274-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18562471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice