Provider Demographics
NPI:1376272237
Name:KOMOTOS, LUKE
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:KOMOTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:873 GREELEY AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2070
Mailing Address - Country:US
Mailing Address - Phone:314-960-7160
Mailing Address - Fax:
Practice Address - Street 1:1009 HIGHWAY C
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MO
Practice Address - Zip Code:63068-1425
Practice Address - Country:US
Practice Address - Phone:573-237-3038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220187911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice