1083698781 NPI number — DR. VASILIOS POURNARAS DMD

Table of content: DR. VASILIOS POURNARAS DMD (NPI 1083698781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083698781 NPI number — DR. VASILIOS POURNARAS DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POURNARAS
Provider First Name:
VASILIOS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
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:
1083698781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 44TH AVE. N.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-449-3161
Provider Business Mailing Address Fax Number:
843-449-9785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 44TH AVE. N.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-449-3161
Provider Business Practice Location Address Fax Number:
843-449-9785
Provider Enumeration Date:
12/06/2005

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:  SC3697 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZX3697 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com