=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881819134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FOTIOS MOUMOULIDIS D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 11/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 73 OLD COUNTY RD
-----------------------------------------------------
City | WINDSOR LOCKS
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06096-1564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-627-9784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 CHATSWORTH CT
-----------------------------------------------------
City | EAST GRANBY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06026-9419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-653-6187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 009214
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------