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NPI Code Detail

MEDICARE: DR. JAMES POULOS DDS

MEDICARE: DR. JAMES POULOS DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentist019020091IL

General Provider Information

NPI Number : 1235333154
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JAMES POULOS DDS
Provider Business Mailing Address
First Line : 5470 W MADISON ST
Second Line :
City : CHICAGO
State : IL
Zip : 60644-4031
Country : US
Telephone Number : 773-287-2277
Fax Number : 773-287-2573
Provider Business Practice Location Address
First Line : 5470 W MADISON ST
Second Line :
City : CHICAGO
State : IL
Zip : 60644-4031
Country : US
Telephone Number : 773-287-2277
Fax Number : 773-287-2573
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/13/2007
Last Update Date : 07/08/2007

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