Provider Demographics
NPI:1740343854
Name:FANIKOS, LAURICE SALIB (MS, DMD)
Entity type:Individual
Prefix:DR
First Name:LAURICE
Middle Name:SALIB
Last Name:FANIKOS
Suffix:
Gender:F
Credentials:MS, DMD
Other - Prefix:DR
Other - First Name:LAURICE
Other - Middle Name:
Other - Last Name:SALIB-FANIKOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, DMD
Mailing Address - Street 1:905 GREAT PLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-3031
Mailing Address - Country:US
Mailing Address - Phone:781-343-7447
Mailing Address - Fax:781-343-7448
Practice Address - Street 1:905 GREAT PLAIN AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-3031
Practice Address - Country:US
Practice Address - Phone:781-343-7447
Practice Address - Fax:781-343-7448
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN217511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1740343854Medicare NSC