Healthcare Provider Details

I. General information

NPI: 1174681076
Provider Name (Legal Business Name): TASIOS G. VAKKAS D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 QUAKER RIDGE RD SUITE 212
NEW ROCHELLE NY
10804-2808
US

IV. Provider business mailing address

1565 MIDLAND AVE 2ND FLOOR
BRONXVILLE NY
10708-6039
US

V. Phone/Fax

Practice location:
  • Phone: 914-235-1235
  • Fax: 914-235-0194
Mailing address:
  • Phone: 914-202-9639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number052718
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number240882
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: