Healthcare Provider Details

I. General information

NPI: 1235878745
Provider Name (Legal Business Name): MICHAEL VLASSAKIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E JIMMIE LEEDS RD
GALLOWAY NJ
08205-9567
US

IV. Provider business mailing address

6 LOCUST CT
MOUNT LAUREL NJ
08054-2522
US

V. Phone/Fax

Practice location:
  • Phone: 609-652-0888
  • Fax:
Mailing address:
  • Phone: 609-314-8779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS043641
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02992200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: