Provider Demographics
NPI:1083373609
Name:AGGELIDAKIS, DIMITRI PANAGIS (LMP)
Entity Type:Individual
Prefix:
First Name:DIMITRI
Middle Name:PANAGIS
Last Name:AGGELIDAKIS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11505 BURNHAM DR
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-9173
Mailing Address - Country:US
Mailing Address - Phone:253-858-5152
Mailing Address - Fax:253-858-5153
Practice Address - Street 1:11505 BURNHAM DR
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-9173
Practice Address - Country:US
Practice Address - Phone:253-858-5152
Practice Address - Fax:253-858-5153
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61044627225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000OtherN/A