Provider Demographics
NPI:1255471066
Name:KATECHIS, TASSOS S (DDS)
Entity Type:Individual
Prefix:DR
First Name:TASSOS
Middle Name:S
Last Name:KATECHIS
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 1:17 ROXBURY AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-2711
Mailing Address - Country:US
Mailing Address - Phone:516-944-5300
Mailing Address - Fax:
Practice Address - Street 1:4021 BELL BLVD
Practice Address - Street 2:2ND FL
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2041
Practice Address - Country:US
Practice Address - Phone:718-352-5582
Practice Address - Fax:718-352-5584
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05295311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02784756Medicaid