Provider Demographics
NPI:1598978090
Name:MALTEZOS, ANGELO NICHOLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:NICHOLAS
Last Name:MALTEZOS
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 1:649 N 1ST BANK DR
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-8111
Mailing Address - Country:US
Mailing Address - Phone:847-934-4200
Mailing Address - Fax:847-934-4294
Practice Address - Street 1:649 N 1ST BANK DR
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-8111
Practice Address - Country:US
Practice Address - Phone:847-934-4200
Practice Address - Fax:847-934-4294
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004355Medicaid