Provider Demographics
NPI:1912076597
Name:SOLDATOS, CONSTANTINOS NICHOLA (DMD)
Entity Type:Individual
Prefix:
First Name:CONSTANTINOS
Middle Name:NICHOLA
Last Name:SOLDATOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:GUS
Other - Middle Name:
Other - Last Name:SOLDATOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:510 OHIO AVE S
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-3219
Mailing Address - Country:US
Mailing Address - Phone:386-362-1408
Mailing Address - Fax:386-362-1319
Practice Address - Street 1:510 OHIO AVE S
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-3219
Practice Address - Country:US
Practice Address - Phone:386-362-1408
Practice Address - Fax:386-362-1319
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist