Provider Demographics
NPI:1790474880
Name:NICHOLAS GOULTAS, DDS, PC
Entity Type:Organization
Organization Name:NICHOLAS GOULTAS, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GOULTAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:650-703-7451
Mailing Address - Street 1:1831 POLK ST APT 107
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-3013
Mailing Address - Country:US
Mailing Address - Phone:650-703-7451
Mailing Address - Fax:
Practice Address - Street 1:5011 GEARY BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-2880
Practice Address - Country:US
Practice Address - Phone:650-703-7451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental