Provider Demographics
NPI:1013928845
Name:KOUSTIS, THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:KOUSTIS
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 1:35403 EUCLID AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4568
Mailing Address - Country:US
Mailing Address - Phone:440-942-1161
Mailing Address - Fax:440-918-9625
Practice Address - Street 1:35403 EUCLID AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4568
Practice Address - Country:US
Practice Address - Phone:440-942-1161
Practice Address - Fax:440-918-9625
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4136291Medicare ID - Type Unspecified
V03144Medicare UPIN