Provider Demographics
NPI:1639365588
Name:POTAMIANOS, GAREY (DDS)
Entity Type:Individual
Prefix:
First Name:GAREY
Middle Name:
Last Name:POTAMIANOS
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 1:16 E BURLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2125
Mailing Address - Country:US
Mailing Address - Phone:708-777-1800
Mailing Address - Fax:708-777-1801
Practice Address - Street 1:16 E BURLINGTON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2125
Practice Address - Country:US
Practice Address - Phone:708-777-1800
Practice Address - Fax:708-777-1801
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190211661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice