Healthcare Provider Details

I. General information

NPI: 1396299103
Provider Name (Legal Business Name): DIMITRIOS FAKITSAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST 5TH FLOOR
BOSTON MA
02111-1527
US

IV. Provider business mailing address

45 STUART ST APT 608
BOSTON MA
02116-4742
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number92/SE-FOK-FOG/A/2015
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: