MEDICARE: DR. ANGELA STATHOPOULOS D.D.S.

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
1	1223G0001X	General Practice Dentistry	019.027863	IL
2	1223G0001X	General Practice Dentistry	55697	CA

General Provider Information

NPI Number	:	1235689886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELA STATHOPOULOS D.D.S.

Provider Business Mailing Address
First Line	:	3800 N LAKE SHORE DR
Second Line	:	1E
City	:	CHICAGO
State	:	IL
Zip	:	60613-3301
Country	:	US
Telephone Number	:	847-778-8170
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 N LAKE SHORE DR
Second Line	:	1E
City	:	CHICAGO
State	:	IL
Zip	:	60613-3301
Country	:	US
Telephone Number	:	847-778-8170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	10/06/2016

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