Provider Demographics
NPI:1215391255
Name:BASILAKOS, DIMITRIOS SOTIRIOS (DMD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRIOS
Middle Name:SOTIRIOS
Last Name:BASILAKOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:DIMITRI
Other - Middle Name:
Other - Last Name:BASILAKOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:501 S PRESTON ST
Mailing Address - Street 2:UOFL DEPT. OF SURGICAL AND HOSPITAL DENTISTRY
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1701
Mailing Address - Country:US
Mailing Address - Phone:502-852-3534
Mailing Address - Fax:502-852-8551
Practice Address - Street 1:4420 DIXIE HWY STE 110
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2986
Practice Address - Country:US
Practice Address - Phone:502-447-3323
Practice Address - Fax:913-752-9116
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY98071223G0001X
390200000X
WI1001997-151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program