Provider Demographics
NPI:1598746364
Name:GEORGE D DI TOLA DDS LTD
Entity Type:Organization
Organization Name:GEORGE D DI TOLA DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:DOMINICK
Authorized Official - Last Name:DITOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-865-1214
Mailing Address - Street 1:3521 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-2825
Mailing Address - Country:US
Mailing Address - Phone:708-865-1214
Mailing Address - Fax:708-865-7933
Practice Address - Street 1:3521 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-2825
Practice Address - Country:US
Practice Address - Phone:708-865-1214
Practice Address - Fax:708-865-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016202G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1001668Medicaid