Healthcare Provider Details

I. General information

NPI: 1811036718
Provider Name (Legal Business Name): PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1S224 SUMMIT AVE SUITE 205
OAKBROOK TERRACE IL
60181-3983
US

IV. Provider business mailing address

1S224 SUMMIT AVE SUITE 205
OAKBROOK TERRACE IL
60181-3983
US

V. Phone/Fax

Practice location:
  • Phone: 630-627-3930
  • Fax: 630-627-2148
Mailing address:
  • Phone: 630-627-3930
  • Fax: 630-627-2148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number060-003629
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019030200
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019024971
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019014972
License Number StateIL

VIII. Authorized Official

Name: GEORGE A MANDELARIS
Title or Position: OWNER PERIODONTIST
Credential: DDS
Phone: 630-627-3930