Healthcare Provider Details

I. General information

NPI: 1811362791
Provider Name (Legal Business Name): DIMOULIS DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N 19TH AVE
MELROSE PARK IL
60160-3726
US

IV. Provider business mailing address

818 N 19TH AVE
MELROSE PARK IL
60160-3726
US

V. Phone/Fax

Practice location:
  • Phone: 708-450-1170
  • Fax: 708-450-0008
Mailing address:
  • Phone: 708-450-1170
  • Fax: 708-450-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.030253
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. THEODORE HARRY DIMOULIS
Title or Position: OWNER/DENTIST
Credential: D.M.D.
Phone: 847-651-2692