Provider Demographics
NPI:1235333154
Name:POULOS, JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:POULOS
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 1:5470 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4031
Mailing Address - Country:US
Mailing Address - Phone:773-287-2277
Mailing Address - Fax:773-287-2573
Practice Address - Street 1:5470 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4031
Practice Address - Country:US
Practice Address - Phone:773-287-2277
Practice Address - Fax:773-287-2573
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist