Provider Demographics
NPI:1376694604
Name:KOUTSOUKOS, GEORGE K (DDS, MS)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:K
Last Name:KOUTSOUKOS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 E CALIFORNIA BLVD
Mailing Address - Street 2:APT. #7
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3834
Mailing Address - Country:US
Mailing Address - Phone:213-949-8458
Mailing Address - Fax:
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:SUITE # 1126
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-501-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44201122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics