Healthcare Provider Details

I. General information

NPI: 1861815888
Provider Name (Legal Business Name): VASILIOS A KOSTAKIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 WOODHAVEN BLVD STE C2
ELMHURST NY
11373-5545
US

IV. Provider business mailing address

6070 WOODHAVEN BLVD STE C2
ELMHURST NY
11373-5545
US

V. Phone/Fax

Practice location:
  • Phone: 718-897-6400
  • Fax: 718-997-9710
Mailing address:
  • Phone: 718-897-6400
  • Fax: 718-997-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number059920
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: