Healthcare Provider Details

I. General information

NPI: 1689746497
Provider Name (Legal Business Name): VASILIOS JAMES PAVLAKOS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3904 JUAN TABO NE
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

3904 JUAN TABO NE
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-7526
  • Fax: 505-292-1058
Mailing address:
  • Phone: 505-292-7526
  • Fax: 505-292-1058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1448
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: