Provider Demographics
NPI:1174681076
Name:VAKKAS, TASIOS G (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:TASIOS
Middle Name:G
Last Name:VAKKAS
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 MIDLAND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-6039
Mailing Address - Country:US
Mailing Address - Phone:914-202-9639
Mailing Address - Fax:
Practice Address - Street 1:77 QUAKER RIDGE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804-2808
Practice Address - Country:US
Practice Address - Phone:914-235-1235
Practice Address - Fax:914-235-0194
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0527181223S0112X
NY240882204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02802202Medicaid
NY02813798Medicaid