Provider Demographics
NPI:1538164405
Name:PANTELIDES, KONSTANTINE (DDS)
Entity type:Individual
Prefix:DR
First Name:KONSTANTINE
Middle Name:
Last Name:PANTELIDES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-2928
Mailing Address - Country:US
Mailing Address - Phone:330-821-0145
Mailing Address - Fax:330-821-6019
Practice Address - Street 1:505 S UNION AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2928
Practice Address - Country:US
Practice Address - Phone:330-821-0145
Practice Address - Fax:330-821-6019
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-58921223G0001X
CA286041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2161057Medicaid
OH9180702OtherDORAL DENTAL