Healthcare Provider Details

I. General information

NPI: 1104126200
Provider Name (Legal Business Name): IRAMIS KOUROMENOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 UNIVERSITY AVE APT#209
BERKELEY CA
94703
US

IV. Provider business mailing address

1721 UNIVERSITY AVE APT 209
BERKELEY CA
94703
US

V. Phone/Fax

Practice location:
  • Phone: 510-323-6533
  • Fax:
Mailing address:
  • Phone: 510-323-6533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number25615
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberAEF885
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: