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General NPI Number Information
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NPI Number | 1811362791
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Entity Type | Organization
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Legal Business Name | DIMOULIS DENTAL P.C.
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Dates
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Enumeration Date | 12/03/2015
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Last Update Date | 12/03/2015
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Provider Practice Location Address
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Address Line | 818 N 19TH AVE
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City | MELROSE PARK
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State | IL
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Zip | 60160-3726
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Country | US
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Telephone | 708-450-1170
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Fax | 708-450-0008
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Provider Business Mailing Address
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Address Line | 818 N 19TH AVE
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City | MELROSE PARK
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State | IL
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Zip | 60160-3726
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Country | US
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Telephone | 708-450-1170
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Fax | 708-450-0008
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. THEODORE HARRY DIMOULIS
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Credential | D.M.D.
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Telephone | 847-651-2692
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.030253
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License Number State | IL
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