Provider Demographics
NPI:1619096435
Name:DIACOLOUKAS, PETER GUS (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:GUS
Last Name:DIACOLOUKAS
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 1:8510 PHILADELPHIA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3015
Mailing Address - Country:US
Mailing Address - Phone:410-574-2800
Mailing Address - Fax:410-238-0026
Practice Address - Street 1:8510 PHILADELPHIA RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-3015
Practice Address - Country:US
Practice Address - Phone:410-574-2800
Practice Address - Fax:410-238-0026
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD133831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice