Healthcare Provider Details

I. General information

NPI: 1285801431
Provider Name (Legal Business Name): NIKOLAOS LAOUTARIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 MAIN ST
CHESTER NJ
07930-2530
US

IV. Provider business mailing address

31 MAIN ST
CHESTER NJ
07930-2530
US

V. Phone/Fax

Practice location:
  • Phone: 908-879-2634
  • Fax:
Mailing address:
  • Phone: 908-879-2634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02199000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: