Provider Demographics
NPI:1104126200
Name:KOUROMENOS, IRAMIS
Entity type:Individual
Prefix:
First Name:IRAMIS
Middle Name:
Last Name:KOUROMENOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 UNIVERSITY AVE APT 209
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703
Mailing Address - Country:US
Mailing Address - Phone:510-323-6533
Mailing Address - Fax:
Practice Address - Street 1:1721 UNIVERSITY AVE APT#209
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703
Practice Address - Country:US
Practice Address - Phone:510-323-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25615124Q00000X
CAAEF885126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No126800000XDental ProvidersDental Assistant