Provider Demographics
NPI:1467940791
Name:EMMANOUILIDIS, PANAGIOTIS (DDS)
Entity Type:Individual
Prefix:
First Name:PANAGIOTIS
Middle Name:
Last Name:EMMANOUILIDIS
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 1:412 E 55TH ST APT 10C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-5115
Mailing Address - Country:US
Mailing Address - Phone:646-637-2604
Mailing Address - Fax:
Practice Address - Street 1:345 E 24TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4020
Practice Address - Country:US
Practice Address - Phone:646-637-2604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000911223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000091Medicaid