1588703490 NPI number — PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC

Table of content: (NPI 1588703490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588703490 NPI number — PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LTD
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588703490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1S224 SUMMIT AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
OAKBROOK TERRACE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60181-3983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-627-3930
Provider Business Mailing Address Fax Number:
630-627-2148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1875 DEMPSTER ST
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
PARK RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60068-1186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-698-1180
Provider Business Practice Location Address Fax Number:
847-698-1185
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANDELARIS
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER PERIODONTIST
Authorized Official Telephone Number:
630-627-3930

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  019030200 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 019014972 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 019024971 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 124Q00000X , with the licence number: 020005282 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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