Provider Demographics
NPI:1609081421
Name:GEROULIS, NICK ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:ALBERT
Last Name:GEROULIS
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 1:3340 S OAK PARK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:708-484-4422
Mailing Address - Fax:708-484-4427
Practice Address - Street 1:3340 S OAK PARK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-484-4422
Practice Address - Fax:708-484-4427
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice