Provider Demographics
NPI:1164814588
Name:KAVAKOGLOU, SOFIA (DMD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:KAVAKOGLOU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 BARTOW AVE
Practice Address - Street 2:#218B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4614
Practice Address - Country:US
Practice Address - Phone:718-249-9337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-22
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058521-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice