MEDICARE: DR. KATHERINE KOUTSOURELIS 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	122300000X	Dentist	30.024461	OH

General Provider Information

NPI Number	:	1871972240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHERINE KOUTSOURELIS DDS

Provider Business Mailing Address
First Line	:	7123 PEARL RD
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-4975
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7123 PEARL RD
Second Line	:
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-4975
Country	:	US
Telephone Number	:	440-888-6783
Fax Number	:

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

Provider Enumeration Date	:	05/19/2015
Last Update Date	:	05/19/2015

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