Provider Demographics
NPI:1447989769
Name:KOUTSOUBIS, ARISTIDES (DMD)
Entity type:Individual
Prefix:DR
First Name:ARISTIDES
Middle Name:
Last Name:KOUTSOUBIS
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 1:2017 BODANYI PL
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6531
Mailing Address - Country:US
Mailing Address - Phone:631-576-7902
Mailing Address - Fax:
Practice Address - Street 1:56 THE CIR
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-2725
Practice Address - Country:US
Practice Address - Phone:844-735-8863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY063408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program