MEDICARE: DR. CONSTANTINE THEODOROPOULOS 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	019-019164	IL

General Provider Information

NPI Number	:	1639322928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONSTANTINE THEODOROPOULOS D.D.S.

Provider Business Mailing Address
First Line	:	5866 N LINCOLN AVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60659-4632
Country	:	US
Telephone Number	:	776-506-8054
Fax Number	:

Provider Business Practice Location Address
First Line	:	5866 N LINCOLN AVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60659-4632
Country	:	US
Telephone Number	:	776-506-8054
Fax Number	:

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

Provider Enumeration Date	:	10/30/2008
Last Update Date	:	10/30/2008

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