Healthcare Provider Details

I. General information

NPI: 1093724585
Provider Name (Legal Business Name): GEORGE ANDREW SOURIS DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26777 LORAIN RD SUITE 214
NORTH OLMSTED OH
44070-3200
US

IV. Provider business mailing address

26777 LORAIN RD SUITE 214
NORTH OLMSTED OH
44070-3200
US

V. Phone/Fax

Practice location:
  • Phone: 440-734-1146
  • Fax: 440-734-6716
Mailing address:
  • Phone: 440-734-1146
  • Fax: 440-734-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30018793
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: