Healthcare Provider Details

I. General information

NPI: 1811623788
Provider Name (Legal Business Name): JDM DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6315 N MILWAUKEE AVE
CHICAGO IL
60646-3760
US

IV. Provider business mailing address

1701 N SHEFFIELD AVE STE 101
CHICAGO IL
60614-5549
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-1493
  • Fax:
Mailing address:
  • Phone: 312-337-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN D MANIKOWSKI
Title or Position: PRESIDENT
Credential: DDS
Phone: 312-213-4179