Healthcare Provider Details

I. General information

NPI: 1609890730
Provider Name (Legal Business Name): MICHAEL J. KOKORELIS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 HARTFORD RD
HAMPTON VA
23666-2575
US

IV. Provider business mailing address

2113 HARTFORD RD
HAMPTON VA
23666-2575
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-1572
  • Fax: 727-827-8895
Mailing address:
  • Phone: 757-827-1572
  • Fax: 727-827-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401005924
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: