Provider Demographics
NPI:1518191295
Name:POWELL AND MARTELLO P.C.
Entity Type:Organization
Organization Name:POWELL AND MARTELLO P.C.
Other - Org Name:ORAL SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-464-6500
Mailing Address - Street 1:10241 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1279
Mailing Address - Country:US
Mailing Address - Phone:815-464-6500
Mailing Address - Fax:815-464-6503
Practice Address - Street 1:10241 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1279
Practice Address - Country:US
Practice Address - Phone:815-464-6500
Practice Address - Fax:815-464-6503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210017501223S0112X
IL0210014871223S0112X
0210022011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty