Provider Demographics
NPI:1336297068
Name:GIANNOS, ROULA P (DMD)
Entity Type:Individual
Prefix:
First Name:ROULA
Middle Name:P
Last Name:GIANNOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 E MAXWELL DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1403
Mailing Address - Country:US
Mailing Address - Phone:617-905-4395
Mailing Address - Fax:
Practice Address - Street 1:1 PEARL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:ME
Practice Address - Zip Code:04843-1919
Practice Address - Country:US
Practice Address - Phone:207-236-3381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211731223G0001X
ME40201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0210021Medicaid