Provider Demographics
NPI:1184795502
Name:NOPOULOS, GUS GEORGE (DDS)
Entity type:Individual
Prefix:MR
First Name:GUS
Middle Name:GEORGE
Last Name:NOPOULOS
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 1:11230 N TATUM BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028
Mailing Address - Country:US
Mailing Address - Phone:602-404-1414
Mailing Address - Fax:602-404-1440
Practice Address - Street 1:11230 N TATUM BLVD
Practice Address - Street 2:STE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:602-404-1414
Practice Address - Fax:602-404-1440
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2248122300000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6381150001Medicare NSC