Provider Demographics
NPI:1316077498
Name:PROUSSAEFS, PERIKLIS (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:PERIKLIS
Middle Name:
Last Name:PROUSSAEFS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3585 TELEGRAPH RD STE C
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3476
Mailing Address - Country:US
Mailing Address - Phone:805-676-1611
Mailing Address - Fax:805-676-1521
Practice Address - Street 1:3585 TELEGRAPH RD STE C
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3476
Practice Address - Country:US
Practice Address - Phone:805-676-1611
Practice Address - Fax:805-676-1521
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA453101223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice