MEDICARE: DR. NICHOLAS MICHAEL POULOS DDS

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	1223P0300X	Periodontics	DN013389	GA
2	1223P0300X	Periodontics	9795	CO

General Provider Information

NPI Number	:	1750505814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS MICHAEL POULOS DDS

Provider Business Mailing Address
First Line	:	700 N BROADWAY STE 1135
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-3444
Country	:	US
Telephone Number	:	303-832-4867
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 N BROADWAY STE 1135
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-3444
Country	:	US
Telephone Number	:	303-832-4867
Fax Number	:

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	02/22/2023

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