Healthcare Provider Details

I. General information

NPI: 1578144556
Provider Name (Legal Business Name): ATHANASIOS NICOLOZAKES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 W 103RD ST
OAK LAWN IL
60453-4869
US

IV. Provider business mailing address

4560 W 103RD ST
OAK LAWN IL
60453-4869
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-5155
  • Fax:
Mailing address:
  • Phone: 708-423-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033194
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: