Provider Demographics
NPI:1114181310
Name:PANOMITROS, NICHOLAS ELIAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ELIAS
Last Name:PANOMITROS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 08404
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-0404
Mailing Address - Country:US
Mailing Address - Phone:312-733-3343
Mailing Address - Fax:312-243-9868
Practice Address - Street 1:1918 S BLUE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3015
Practice Address - Country:US
Practice Address - Phone:312-733-3343
Practice Address - Fax:312-243-9868
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190217131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice