Provider Demographics
NPI:1780808576
Name:KOUSOURNAS, STEVEN K (DMD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:K
Last Name:KOUSOURNAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 BURNSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3533
Mailing Address - Country:US
Mailing Address - Phone:860-291-9676
Mailing Address - Fax:860-289-2580
Practice Address - Street 1:567 BURNSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3533
Practice Address - Country:US
Practice Address - Phone:860-291-9676
Practice Address - Fax:860-289-2580
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT71091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice