Provider Demographics
NPI:1326347089
Name:BOZONELOS, DENISE DIMITRA (DDS)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:DIMITRA
Last Name:BOZONELOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:DIMITRA
Other - Last Name:MANIAKOURAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:39 E COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1385
Mailing Address - Country:US
Mailing Address - Phone:708-789-9289
Mailing Address - Fax:708-789-9285
Practice Address - Street 1:39 E COLORADO AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1385
Practice Address - Country:US
Practice Address - Phone:708-789-9289
Practice Address - Fax:708-789-9285
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028614122300000X
IL021.0025341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentist