Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 21447 | MA |
NPI | 1053459123 |
---|---|
Provider Name | Dr. Petros D. Damoulis |
First Address | Brookline, MA 02446-2801 |
Second Address | Boston, MA 02111-1527 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2007 |
Last Update Date | 08/07/2007 |