Provider Demographics
NPI:1326237595
Name:PROUSSAEFS, KONSTANTINOS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KONSTANTINOS
Middle Name:
Last Name:PROUSSAEFS
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 1:3652 YOUNG WOLF DR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-0249
Mailing Address - Country:US
Mailing Address - Phone:805-582-0785
Mailing Address - Fax:805-582-0785
Practice Address - Street 1:1445 E LOS ANGELES AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2817
Practice Address - Country:US
Practice Address - Phone:805-582-0785
Practice Address - Fax:805-582-0785
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50439122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist