Provider Demographics
NPI:1801208202
Name:METROSMILES - GAGE PARK DENTAL PC
Entity Type:Organization
Organization Name:METROSMILES - GAGE PARK DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOS
Authorized Official - Middle Name:
Authorized Official - Last Name:TSALIAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-925-5020
Mailing Address - Street 1:5825 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-3212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5825 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-3212
Practice Address - Country:US
Practice Address - Phone:773-925-5020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty