1457412264 NPI number — DR. ELIAS KOUVALIS DDS

Table of content: DR. ELIAS KOUVALIS DDS (NPI 1457412264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457412264 NPI number — DR. ELIAS KOUVALIS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOUVALIS
Provider First Name:
ELIAS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457412264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13911 RIDGEDALE DRIVE, SUITE 395
Provider Second Line Business Mailing Address:
PARK DENTAL RIDGEPARK
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-545-8603
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13911 RIDGEDALE DR
Provider Second Line Business Practice Location Address:
SUITE 395
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-1771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-545-8603
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D11378 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 603023800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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