Provider Demographics
NPI:1598799694
Name:KOUSOULIS, PETER T (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:T
Last Name:KOUSOULIS
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 1:501 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147
Mailing Address - Country:US
Mailing Address - Phone:215-925-7299
Mailing Address - Fax:215-924-4108
Practice Address - Street 1:501 SOUTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147
Practice Address - Country:US
Practice Address - Phone:215-925-7299
Practice Address - Fax:215-925-4108
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027559L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice