Healthcare Provider Details

I. General information

NPI: 1821250630
Provider Name (Legal Business Name): ALEXANDER CONSTANTINE TZANOS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CONGRESS PKWY STE D
CRYSTAL LAKE IL
60014-6247
US

IV. Provider business mailing address

411 E CONGRESS PKWY STE D
CRYSTAL LAKE IL
60014-6247
US

V. Phone/Fax

Practice location:
  • Phone: 814-455-6550
  • Fax:
Mailing address:
  • Phone: 814-455-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019027377
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: