Provider Demographics
NPI:1922843176
Name:KONSTANTINIDOU, ELISAVET
Entity type:Individual
Prefix:
First Name:ELISAVET
Middle Name:
Last Name:KONSTANTINIDOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 BLACK FOREST LN STE 300
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5306
Mailing Address - Country:US
Mailing Address - Phone:703-230-6784
Mailing Address - Fax:
Practice Address - Street 1:12700 BLACK FOREST LN STE 300
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5306
Practice Address - Country:US
Practice Address - Phone:703-230-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014171391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics