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NPI Code Detail

MEDICARE: MADISON PINE DENTAL

MEDICARE: MADISON PINE DENTAL
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
11223G0001XGeneral Practice Dentistry

General Provider Information

NPI Number : 1942322664
Entity Type Code : Organization
Provider Name (Legal Business Name) : MADISON PINE DENTAL
Provider Business Mailing Address
First Line : 5470 W MADISON ST
Second Line :
City : CHICAGO
State : IL
Zip : 60644-4031
Country : US
Telephone Number : 773-287-3939
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 : 773-287-3939
Fax Number : 773-287-2573
Authorized Official
Title or Position : DENTIST
Name : DR. JAMES POULOS
Credential :
Telephone Number : 773-287-3939
Provider Enumeration Date : 04/04/2007
Last Update Date : 08/22/2020

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Directions to “MADISON PINE DENTAL ” Practice Location

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