Provider Demographics
NPI:1568768489
Name:KAVOUKLIS, NICHOLAS MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:KAVOUKLIS
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 1:4010 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-1264
Mailing Address - Country:US
Mailing Address - Phone:813-793-7046
Mailing Address - Fax:813-831-1599
Practice Address - Street 1:4010 W STATE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1264
Practice Address - Country:US
Practice Address - Phone:813-793-7046
Practice Address - Fax:813-831-1599
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN109291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice