Provider Demographics
NPI:1700863552
Name:MIHALOPULOS, JENNIFER E (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:MIHALOPULOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1668
Mailing Address - Country:US
Mailing Address - Phone:618-833-4471
Mailing Address - Fax:618-833-8878
Practice Address - Street 1:103 N. APPLEKNOCKER
Practice Address - Street 2:
Practice Address - City:COBDEN
Practice Address - State:IL
Practice Address - Zip Code:62920-2117
Practice Address - Country:US
Practice Address - Phone:618-893-4005
Practice Address - Fax:618-893-1476
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-05-19
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-05-01
Provider Licenses
StateLicense IDTaxonomies
IL019-0269161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-026916Medicaid