Provider Demographics
NPI:1134176316
Name:KABOURIDOU, OLGA MARIA (DMD)
Entity type:Individual
Prefix:DR
First Name:OLGA
Middle Name:MARIA
Last Name:KABOURIDOU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:OLGA
Other - Middle Name:MARIA
Other - Last Name:KABOURIDOU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1901 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2216
Mailing Address - Country:US
Mailing Address - Phone:215-551-7300
Mailing Address - Fax:215-551-7401
Practice Address - Street 1:1901 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2216
Practice Address - Country:US
Practice Address - Phone:215-551-7300
Practice Address - Fax:215-551-7401
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011373800002Medicaid