Healthcare Provider Details

I. General information

NPI: 1962592865
Provider Name (Legal Business Name): JOHN DIMOULIS DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5780 N LINCOLN AVE
CHICAGO IL
60659-4721
US

IV. Provider business mailing address

5780 N LINCOLN AVE
CHICAGO IL
60659-4721
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-1754
  • Fax: 773-769-1350
Mailing address:
  • Phone: 773-769-1754
  • Fax: 773-769-1350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: