Provider Demographics
NPI:1992722896
Name:ATHANASOPOULOS, ANASTASIOS (DMD)
Entity type:Individual
Prefix:MR
First Name:ANASTASIOS
Middle Name:
Last Name:ATHANASOPOULOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 EASTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-1633
Mailing Address - Country:US
Mailing Address - Phone:781-598-2232
Mailing Address - Fax:781-598-2264
Practice Address - Street 1:475 EASTERN AVENUE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-1633
Practice Address - Country:US
Practice Address - Phone:781-598-2232
Practice Address - Fax:781-598-2264
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA185901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX12091OtherBCBS
MA0208981Medicaid