Provider Demographics
NPI:1457549610
Name:BACOPOULOU, CONSTANTINA (DDS)
Entity Type:Individual
Prefix:
First Name:CONSTANTINA
Middle Name:
Last Name:BACOPOULOU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:141 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1014
Practice Address - Country:US
Practice Address - Phone:203-969-0802
Practice Address - Fax:203-357-0162
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104131223G0001X
NY054899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236354Medicaid