=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659538445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW JAMES SAMPALIS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2008
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4560 W 103RD ST
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-4869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-423-5155
-----------------------------------------------------
Fax | 708-423-0719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4560 W 103RD ST
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-4869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-423-5155
-----------------------------------------------------
Fax | 708-423-0719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019014671
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------