Provider Demographics
NPI:1619138229
Name:POULOS, JAIME M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:M
Last Name:POULOS
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 1:6 DITMAR LN
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-5220
Mailing Address - Country:US
Mailing Address - Phone:516-729-6799
Mailing Address - Fax:
Practice Address - Street 1:120 NEW YORK AVE STE 2W
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2743
Practice Address - Country:US
Practice Address - Phone:631-673-3755
Practice Address - Fax:631-673-3433
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190267971223G0001X
NY0520741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice