Provider Demographics
NPI:1679695407
Name:KOUSOULIS, ELISABETH T (DDS)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:T
Last Name:KOUSOULIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:A
Other - Last Name:KOUSOULIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:7922 W CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-1917
Mailing Address - Country:US
Mailing Address - Phone:610-853-4350
Mailing Address - Fax:610-853-4312
Practice Address - Street 1:7922 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-1917
Practice Address - Country:US
Practice Address - Phone:610-853-4350
Practice Address - Fax:610-853-4312
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020859L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice