Healthcare Provider Details

I. General information

NPI: 1285837344
Provider Name (Legal Business Name): PETER A. STATHOULOPOULOS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 HIGHLAND ST
WORCESTER MA
01609-2231
US

IV. Provider business mailing address

199 HIGHLAND ST
WORCESTER MA
01609-2231
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-7171
  • Fax: 508-755-5409
Mailing address:
  • Phone: 508-755-7171
  • Fax: 508-755-5409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMS062768OC
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: