Provider Demographics
NPI:1447361332
Name:KOUTLAS, IOANNIS (DDS)
Entity type:Individual
Prefix:
First Name:IOANNIS
Middle Name:
Last Name:KOUTLAS
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 1:515 DELAWARE ST SE
Mailing Address - Street 2:16-116 MOOS TOWER
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0357
Mailing Address - Country:US
Mailing Address - Phone:612-626-5844
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST SE
Practice Address - Street 2:16-116 MOOS TOWER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0357
Practice Address - Country:US
Practice Address - Phone:612-626-5844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND111021223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology