MEDICARE: DR. OLGA MARIA KABOURIDOU D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS036116	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134176316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLGA MARIA KABOURIDOU D.M.D.

Provider Business Mailing Address
First Line	:	1901 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2216
Country	:	US
Telephone Number	:	215-551-7300
Fax Number	:	215-551-7401

Provider Business Practice Location Address
First Line	:	1901 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2216
Country	:	US
Telephone Number	:	215-551-7300
Fax Number	:	215-551-7401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	02/14/2013

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