Provider Demographics
NPI:1932597606
Name:JOHN G POULOS DDS
Entity Type:Organization
Organization Name:JOHN G POULOS DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:POULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-262-0644
Mailing Address - Street 1:22 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3165
Mailing Address - Country:US
Mailing Address - Phone:631-262-0644
Mailing Address - Fax:631-262-0645
Practice Address - Street 1:22 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3165
Practice Address - Country:US
Practice Address - Phone:631-262-0644
Practice Address - Fax:631-262-0645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313471223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty