Healthcare Provider Details

I. General information

NPI: 1356452932
Provider Name (Legal Business Name): ATHANASIOS KOKKAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2689 E GULF TO LAKE HWY
INVERNESS FL
34453-3216
US

IV. Provider business mailing address

2502 N ROCKY POINT DR SUITE 1000-CREDENTIALING
TAMPA FL
33607-1421
US

V. Phone/Fax

Practice location:
  • Phone: 352-637-1114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16761
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: