Healthcare Provider Details

I. General information

NPI: 1255317301
Provider Name (Legal Business Name): ANDREW P SOULIMIOTIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2172 LAVISTA RD NE
ATLANTA GA
30329-3916
US

IV. Provider business mailing address

2172 LAVISTA RD NE
ATLANTA GA
30329-3916
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-2722
  • Fax: 404-343-1845
Mailing address:
  • Phone: 404-321-2722
  • Fax: 404-343-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number011885
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberBS3815
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: