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General NPI Number Information
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NPI Number | 1417223470
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Entity Type | Organization
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Legal Business Name | A-DENTA CARE SPECIALIST PC
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Dates
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Enumeration Date | 03/23/2012
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Last Update Date | 03/23/2012
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Provider Practice Location Address
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Address Line | 5780 N LINCOLN AVE
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City | CHICAGO
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State | IL
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Zip | 60659-4721
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Country | US
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Telephone | 773-769-1754
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Fax | 773-769-1370
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Provider Business Mailing Address
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Address Line | 5780 N LINCOLN AVE
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City | CHICAGO
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State | IL
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Zip | 60659-4721
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Country | US
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Telephone | 773-769-1754
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Fax | 773-769-1370
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN DIMOULIS
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Credential | DDS MS
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Telephone | 773-769-1754
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 021002414
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 021002411
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 021001402
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License Number State | IL
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