Provider Demographics
NPI:1669466371
Name:KAKOURAS, ATHANASIOS PANAGIOTIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:ATHANASIOS
Middle Name:PANAGIOTIS
Last Name:KAKOURAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:TOMMY
Other - Middle Name:
Other - Last Name:KAKOURAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3700 STOKES AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4748
Mailing Address - Country:US
Mailing Address - Phone:704-281-9991
Mailing Address - Fax:
Practice Address - Street 1:11020 S TRYON ST
Practice Address - Street 2:SUITE 401
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-6530
Practice Address - Country:US
Practice Address - Phone:704-504-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC78381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902XJMedicaid
NC902XJOtherBLUECROSS/BLUESHIELD