Provider Demographics
NPI:1487009577
Name:TARASIDIS, ELENI B
Entity Type:Individual
Prefix:
First Name:ELENI
Middle Name:B
Last Name:TARASIDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10160 SUPERIOR WAY
Mailing Address - Street 2:
Mailing Address - City:AMELIA COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23002-4744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10160 SUPERIOR WAY
Practice Address - Street 2:
Practice Address - City:AMELIA COURT HOUSE
Practice Address - State:VA
Practice Address - Zip Code:23002-4744
Practice Address - Country:US
Practice Address - Phone:804-561-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014156091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice