Provider Demographics
NPI:1992246458
Name:MASI DENTAL GROUP PC
Entity type:Organization
Organization Name:MASI DENTAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STANISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVTUN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-264-2067
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 1:171 WATERTOWN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2571
Practice Address - Country:US
Practice Address - Phone:617-467-5113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856247261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental