Provider Demographics
NPI:1730286188
Name:KOUTROS, ELIAS GEORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:GEORGE
Last Name:KOUTROS
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 1:7 ARBOR CLUB DR UNIT 106
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2607
Mailing Address - Country:US
Mailing Address - Phone:401-261-9734
Mailing Address - Fax:
Practice Address - Street 1:1970 UNIVERSITY AVE STE 316
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5202
Practice Address - Country:US
Practice Address - Phone:951-213-3460
Practice Address - Fax:951-213-3449
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN026801223G0001X
CADDS1032621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice