Provider Demographics
NPI:1487774634
Name:KOUMOUTSEAS, CHRISTOS
Entity type:Individual
Prefix:DR
First Name:CHRISTOS
Middle Name:
Last Name:KOUMOUTSEAS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CHRISTOS
Other - Middle Name:
Other - Last Name:KOUMOUTSEAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1417 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-2915
Mailing Address - Country:US
Mailing Address - Phone:617-929-4300
Mailing Address - Fax:
Practice Address - Street 1:1417DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02122
Practice Address - Country:US
Practice Address - Phone:617-929-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA176221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2177598Medicaid