Provider Demographics
NPI:1508849464
Name:KOUTROULAKIS, HARRY J (DMD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:J
Last Name:KOUTROULAKIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9384
Mailing Address - Country:US
Mailing Address - Phone:803-438-3540
Mailing Address - Fax:
Practice Address - Street 1:1 PLAZA DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9384
Practice Address - Country:US
Practice Address - Phone:803-438-3540
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ2807Medicaid