MEDICARE: DR. KONSTANTINOS PROUSSAEFS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	50439	CA

General Provider Information

NPI Number	:	1326237595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KONSTANTINOS PROUSSAEFS D.D.S.

Provider Business Mailing Address
First Line	:	3652 YOUNG WOLF DR
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-0249
Country	:	US
Telephone Number	:	805-582-0785
Fax Number	:	805-582-0785

Provider Business Practice Location Address
First Line	:	1445 E LOS ANGELES AVE
Second Line	:	SUITE 300
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-2817
Country	:	US
Telephone Number	:	805-582-0785
Fax Number	:	805-582-0785

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2007
Last Update Date	:	10/23/2007

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