Provider Demographics
NPI:1548332141
Name:POULOS, MICHAEL N (DMD,MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:N
Last Name:POULOS
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BROADWAY
Mailing Address - Street 2:SUITE 1135
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-3421
Mailing Address - Country:US
Mailing Address - Phone:303-832-4867
Mailing Address - Fax:303-861-7267
Practice Address - Street 1:700 BROADWAY
Practice Address - Street 2:SUITE 1135
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-3421
Practice Address - Country:US
Practice Address - Phone:303-832-4867
Practice Address - Fax:303-861-7267
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1040301223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics