Provider Demographics
NPI:1174552319
Name:DEMETRIOS G. POURLOS, DDS, PA
Entity type:Organization
Organization Name:DEMETRIOS G. POURLOS, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:POURLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-542-6533
Mailing Address - Street 1:7251 PINEVILLE MATTHEWS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-6158
Mailing Address - Country:US
Mailing Address - Phone:704-542-6533
Mailing Address - Fax:704-540-1849
Practice Address - Street 1:7251 PINEVILLE MATTHEWS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-6158
Practice Address - Country:US
Practice Address - Phone:704-542-6533
Practice Address - Fax:704-540-1849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC97025OtherBLUE CROSS BLUE SHIELD