Provider Demographics
NPI:1417223470
Name:A-DENTA CARE SPECIALIST PC
Entity Type:Organization
Organization Name:A-DENTA CARE SPECIALIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMOULIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:773-769-1754
Mailing Address - Street 1:5780 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4721
Mailing Address - Country:US
Mailing Address - Phone:773-769-1754
Mailing Address - Fax:773-769-1370
Practice Address - Street 1:5780 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4721
Practice Address - Country:US
Practice Address - Phone:773-769-1754
Practice Address - Fax:773-769-1370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210024141223E0200X
IL0210024111223E0200X
IL0210014021223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619133345OtherNPI DENTAL PROVIDER
IL136645657OtherNPI DENTAL PROVIDER
IL1962592865OtherDENTAL PROVIDER