Provider Demographics
NPI:1407476633
Name:DEMETRIOUS, ADEL (DENTIST)
Entity Type:Individual
Prefix:
First Name:ADEL
Middle Name:
Last Name:DEMETRIOUS
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 NORTH ATLANTIC, AVE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:DAYTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118
Mailing Address - Country:US
Mailing Address - Phone:386-672-4321
Mailing Address - Fax:386-672-4321
Practice Address - Street 1:2727 NORTH ATLANTIC, AVE
Practice Address - Street 2:SUITE 121
Practice Address - City:DAYTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118
Practice Address - Country:US
Practice Address - Phone:386-672-4321
Practice Address - Fax:386-672-4321
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL88391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty