Provider Demographics
NPI:1538627310
Name:KALLIS, NICKOLAOS ZACKARY (DMD)
Entity type:Individual
Prefix:DR
First Name:NICKOLAOS
Middle Name:ZACKARY
Last Name:KALLIS
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 1:63 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-2024
Mailing Address - Country:US
Mailing Address - Phone:941-720-2529
Mailing Address - Fax:
Practice Address - Street 1:1010 MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2212
Practice Address - Country:US
Practice Address - Phone:862-881-4153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0602771223X0400X
NJ22DI027411001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics