Healthcare Provider Details

I. General information

NPI: 1225200140
Provider Name (Legal Business Name): CICERO DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7110 W 127TH ST SUITE 220
PALOS HEIGHTS IL
60463-1571
US

IV. Provider business mailing address

7110 W 127TH ST SUITE 220
PALOS HEIGHTS IL
60463-1571
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-1841
  • Fax: 708-923-7025
Mailing address:
  • Phone: 708-923-1841
  • Fax: 708-923-7025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. CHRISTOS A TSALIAGOS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 708-923-1841