Healthcare Provider Details

I. General information

NPI: 1932282324
Provider Name (Legal Business Name): MICHAEL KOKOLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 21 BELL BLVD 2ND FL
BAYSIDE NY
11361
US

IV. Provider business mailing address

214-35 42 AVE
BAYSIDE NY
11361
US

V. Phone/Fax

Practice location:
  • Phone: 718-352-5582
  • Fax: 718-352-5584
Mailing address:
  • Phone: 718-352-5582
  • Fax: 718-352-5584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0496241
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: