Healthcare Provider Details

I. General information

NPI: 1568839827
Provider Name (Legal Business Name): KATERINA SIOUTIS DMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E BALTIMORE AVE STE 2
MEDIA PA
19063-3538
US

IV. Provider business mailing address

415 E BALTIMORE AVE STE 2
MEDIA PA
19063-3538
US

V. Phone/Fax

Practice location:
  • Phone: 610-566-3600
  • Fax:
Mailing address:
  • Phone: 610-566-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. DEAN KANELLOPOULOS
Title or Position: OFFICE MANAGER
Credential:
Phone: 610-566-3600