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General NPI Number Information
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NPI Number | 1881158301
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Entity Type | Individual
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Provider Name | EMILY POULOS D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 01/29/2019
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Last Update Date | 01/21/2021
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Provider Practice Location Address
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Address Line | 1113 S SIGNAL BUTTE RD
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City | MESA
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State | AZ
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Zip | 85208-3918
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Country | US
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Telephone | 480-582-1199
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Fax |
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Provider Business Mailing Address
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Address Line | 9857 E EL MORO AVE
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City | MESA
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State | AZ
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Zip | 85208-5867
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Country | US
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Telephone | 919-475-2767
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D010240
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 4167-20
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License Number State | MS
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