Healthcare Provider Details

I. General information

NPI: 1669692547
Provider Name (Legal Business Name): MICHAEL J. KOKORELIS, DMD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 06/16/2008
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: 757-827-8895
Mailing address:
  • Phone: 757-827-1572
  • Fax: 757-827-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MICHAEL J. KOKORELIS
Title or Position: PRESIDENT
Credential: DMD
Phone: 757-827-1572