Provider Demographics
NPI:1457412264
Name:KOUVALIS, ELIAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:
Last Name:KOUVALIS
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 1:13911 RIDGEDALE DRIVE, SUITE 395
Mailing Address - Street 2:PARK DENTAL RIDGEPARK
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305
Mailing Address - Country:US
Mailing Address - Phone:952-545-8603
Mailing Address - Fax:
Practice Address - Street 1:13911 RIDGEDALE DR
Practice Address - Street 2:SUITE 395
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1771
Practice Address - Country:US
Practice Address - Phone:952-545-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN603023800Medicaid