Provider Demographics
NPI:1629289731
Name:POURNARAS, NICHOLAS JOHN (DMD)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:POURNARAS
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 1:1801A CHARLESTON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033
Mailing Address - Country:US
Mailing Address - Phone:803-794-5430
Mailing Address - Fax:803-794-0122
Practice Address - Street 1:1801A CHARLESTON HIGHWAY
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033
Practice Address - Country:US
Practice Address - Phone:803-794-5430
Practice Address - Fax:803-794-0122
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9845Medicaid