=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043395205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIMITRIOS GAREFALAKIS DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 03/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4134 E JOPPA RD SUITE 104&105
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21236-2284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-256-3371
-----------------------------------------------------
Fax | 410-256-6848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4134 E JOPPA RD SUITE 104&105
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21236-2284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-256-3371
-----------------------------------------------------
Fax | 410-256-6848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DIMITRIOS GAREFALAKIS
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 410-256-3371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 12207
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------