Healthcare Provider Details

I. General information

NPI: 1386098390
Provider Name (Legal Business Name): PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W WEBSTER AVE
CHICAGO IL
60614-3502
US

IV. Provider business mailing address

1S224 SUMMIT AVE SUITE 205
OAKBROOK TERRACE IL
60181-3983
US

V. Phone/Fax

Practice location:
  • Phone: 630-627-3930
  • Fax:
Mailing address:
  • Phone: 630-627-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021001938
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021002676
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021002351
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GEORGE MANDELARIS
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 630-627-3930