Healthcare Provider Details

I. General information

NPI: 1649612235
Provider Name (Legal Business Name): KONSTANTINOS VAZOURAS DDS, MPHIL, MDSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 07/21/2022
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

1 KNEELAND STREET
BOSTON MA
06111
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6585
  • Fax:
Mailing address:
  • Phone: 617-636-6585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN1859085
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: