Provider Demographics
NPI:1205842630
Name:PATRICOSKI, MICHAEL T (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:PATRICOSKI
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 1:6400 W COLLEGE DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1785
Mailing Address - Country:US
Mailing Address - Phone:708-597-4155
Mailing Address - Fax:708-597-4155
Practice Address - Street 1:6400 W COLLEGE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1785
Practice Address - Country:US
Practice Address - Phone:708-597-4155
Practice Address - Fax:708-597-4155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist