Provider Demographics
NPI:1053479972
Name:DIAMANTAKOS, DEMETRIOS (DDS PC)
Entity Type:Individual
Prefix:
First Name:DEMETRIOS
Middle Name:
Last Name:DIAMANTAKOS
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 W MORELAND AVE
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101
Mailing Address - Country:US
Mailing Address - Phone:630-543-7180
Mailing Address - Fax:
Practice Address - Street 1:96 W MORELAND AVE
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101
Practice Address - Country:US
Practice Address - Phone:630-543-7180
Practice Address - Fax:630-543-9803
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019 236981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice