MEDICARE: CHRIS NIKOLOVSKI DDS PC

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	019024482	IL

General Provider Information

NPI Number	:	1497293906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRIS NIKOLOVSKI DDS PC

Provider Business Mailing Address
First Line	:	3838 W 111TH ST
Second Line	:	SUITE105
City	:	CHICAGO
State	:	IL
Zip	:	60655-4095
Country	:	US
Telephone Number	:	773-779-1415
Fax Number	:	773-779-1785

Provider Business Practice Location Address
First Line	:	3838 W 111TH ST
Second Line	:	SUITE105
City	:	CHICAGO
State	:	IL
Zip	:	60655-4095
Country	:	US
Telephone Number	:	773-779-1415
Fax Number	:	773-779-1785

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHRIS NIKOLOVSKI
Credential	:	DDS
Telephone Number	:	708-705-0578

Provider Enumeration Date	:	02/03/2017
Last Update Date	:	02/03/2017

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