Healthcare Provider Details

I. General information

NPI: 1083920227
Provider Name (Legal Business Name): NICHOLAS CALLAHAN MPH DMD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612
US

IV. Provider business mailing address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-2379
  • Fax: 312-996-5987
Mailing address:
  • Phone: 312-413-2379
  • Fax: 312-996-5987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019031599
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021102880
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number036147058
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number019031599
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number021002880
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number036147058
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: