Provider Demographics
NPI:1144594441
Name:STATHOPOULOS, NIKOLAS MARIOS (DDS)
Entity Type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:MARIOS
Last Name:STATHOPOULOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19682 HESPERIAN BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4752
Mailing Address - Country:US
Mailing Address - Phone:510-264-1410
Mailing Address - Fax:510-264-1406
Practice Address - Street 1:19682 HESPERIAN BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4752
Practice Address - Country:US
Practice Address - Phone:510-264-1410
Practice Address - Fax:510-264-1406
Is Sole Proprietor?:No
Enumeration Date:2012-03-04
Last Update Date:2012-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA520051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice