Provider Demographics
NPI:1851655609
Name:COSTOPOULOS, GREG (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:
Last Name:COSTOPOULOS
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 1:1730 NOVATO BLVD
Mailing Address - Street 2:SUITE I
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-3048
Mailing Address - Country:US
Mailing Address - Phone:415-897-4191
Mailing Address - Fax:415-897-4192
Practice Address - Street 1:1730 NOVATO BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3048
Practice Address - Country:US
Practice Address - Phone:415-897-4191
Practice Address - Fax:415-897-4192
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA392481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics