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General NPI Number Information
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NPI Number | 1316077498
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Entity Type | Individual
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Provider Name | PERIKLIS PROUSSAEFS DDS, MS
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Gender | Male
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 06/12/2020
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Provider Practice Location Address
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Address Line | 3585 TELEGRAPH RD STE C
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City | VENTURA
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State | CA
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Zip | 93003-3476
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Country | US
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Telephone | 805-676-1611
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Fax | 805-676-1521
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Provider Business Mailing Address
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Address Line | 3585 TELEGRAPH RD STE C
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City | VENTURA
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State | CA
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Zip | 93003-3476
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Country | US
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Telephone | 805-676-1611
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Fax | 805-676-1521
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 45310
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 45310
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License Number State | CA
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