MEDICARE: DR. JAMES D. PAPANICOLAS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019021831	IL

General Provider Information

NPI Number	:	1053688648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES D. PAPANICOLAS D.D.S.

Provider Business Mailing Address
First Line	:	3218 W 115TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2805
Country	:	US
Telephone Number	:	773-233-6800
Fax Number	:	773-233-7221

Provider Business Practice Location Address
First Line	:	3218 W 115TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2805
Country	:	US
Telephone Number	:	773-233-6800
Fax Number	:	773-233-7221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2011
Last Update Date	:	11/26/2011

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