Provider Demographics
NPI:1881819134
Name:MOUMOULIDIS, FOTIOS (DMD)
Entity Type:Individual
Prefix:DR
First Name:FOTIOS
Middle Name:
Last Name:MOUMOULIDIS
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 1:6 CHATSWORTH CT
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-9419
Mailing Address - Country:US
Mailing Address - Phone:860-653-6187
Mailing Address - Fax:
Practice Address - Street 1:73 OLD COUNTY RD
Practice Address - Street 2:
Practice Address - City:WINDSOR LOCKS
Practice Address - State:CT
Practice Address - Zip Code:06096-1564
Practice Address - Country:US
Practice Address - Phone:860-627-9784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009214122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist