Provider Demographics
NPI:1407981855
Name:KOUMARAS, GEORGE MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MICHAEL
Last Name:KOUMARAS
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 1:143 BOGEY LN
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6858
Mailing Address - Country:US
Mailing Address - Phone:540-389-3655
Mailing Address - Fax:
Practice Address - Street 1:143 BOGEY LN
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6858
Practice Address - Country:US
Practice Address - Phone:540-389-3655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021549-L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery