Provider Demographics
NPI:1134273683
Name:JACK MAVROMATIS DDS, LTD.
Entity type:Organization
Organization Name:JACK MAVROMATIS DDS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAVROMATIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-496-9123
Mailing Address - Street 1:2248 SUNSTATES CT STE 103
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1553
Mailing Address - Country:US
Mailing Address - Phone:757-496-9123
Mailing Address - Fax:757-496-2083
Practice Address - Street 1:2248 SUNSTATES CT STE 103
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1553
Practice Address - Country:US
Practice Address - Phone:757-496-9123
Practice Address - Fax:757-496-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty