Healthcare Provider Details

I. General information

NPI: 1215138672
Provider Name (Legal Business Name): CONSTANTINOS LASKARIDES DMD, DDS, PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST RM 503
BOSTON MA
02111-1527
US

IV. Provider business mailing address

1 KNEELAND ST RM 503
BOSTON MA
02111-1527
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6648
  • Fax: 617-636-6809
Mailing address:
  • Phone: 617-636-6648
  • Fax: 617-636-6809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1855296
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: