Provider Demographics
NPI:1457072126
Name:LAVRENTIADIS, GRIGORIOS
Entity Type:Individual
Prefix:
First Name:GRIGORIOS
Middle Name:
Last Name:LAVRENTIADIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SQUIRE HALL
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-8006
Mailing Address - Country:US
Mailing Address - Phone:716-645-8131
Mailing Address - Fax:
Practice Address - Street 1:215 SQUIRE HALL
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-8006
Practice Address - Country:US
Practice Address - Phone:716-645-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0001411223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics