Provider Demographics
NPI:1063663722
Name:KOMETAS, ATHAS NICHOLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:ATHAS
Middle Name:NICHOLAS
Last Name:KOMETAS
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 1:3162 S ATLANTIC AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:DAYTONA BEACH SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:32118-6286
Mailing Address - Country:US
Mailing Address - Phone:386-760-0030
Mailing Address - Fax:386-788-3873
Practice Address - Street 1:3162 S ATLANTIC AVE
Practice Address - Street 2:SUITE C
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118-6286
Practice Address - Country:US
Practice Address - Phone:386-760-0030
Practice Address - Fax:386-788-3873
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN114311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice