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General NPI Number Information
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NPI Number | 1518370832
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Entity Type | Organization
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Legal Business Name | MAYWOOD FAMILY DENTAL, LTD
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Dates
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Enumeration Date | 06/04/2014
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Last Update Date | 10/13/2014
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Provider Practice Location Address
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Address Line | 1409 S 5TH AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-2128
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Country | US
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Telephone | 708-865-2225
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Fax |
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Provider Business Mailing Address
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Address Line | 1409 S 5TH AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-2128
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAMES POULOS
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Credential |
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Telephone | 708-865-2225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019020091
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License Number State | IL
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