Provider Demographics
NPI:1265642771
Name:VASILIOS J. POURNARAS, D.M.D., L.L.C.
Entity Type:Organization
Organization Name:VASILIOS J. POURNARAS, D.M.D., L.L.C.
Other - Org Name:POURNARAS COSMETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VASILIOS
Authorized Official - Middle Name:J
Authorized Official - Last Name:POURNARAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-449-3161
Mailing Address - Street 1:1211 44TH AVE. N.
Mailing Address - Street 2:100
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577
Mailing Address - Country:US
Mailing Address - Phone:843-449-3161
Mailing Address - Fax:843-449-9785
Practice Address - Street 1:1211 44TH AVE. N.
Practice Address - Street 2:100
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-449-3161
Practice Address - Fax:843-449-9785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC36971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3697Medicaid