Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 136.000264 | IL |
NPI | 1083284160 |
---|---|
Provider Name | Polymnia Vasiliki Tsotsis |
First Address | Saint Louis, MO 63103-1382 |
Second Address | Alton, IL 62002-4700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2021 |
Last Update Date | 30/06/2021 |