Provider Demographics
NPI:1811036718
Name:PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Other - Org Name:PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANDELARIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-627-3930
Mailing Address - Street 1:1S224 SUMMIT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3983
Mailing Address - Country:US
Mailing Address - Phone:630-627-3930
Mailing Address - Fax:630-627-2148
Practice Address - Street 1:1S224 SUMMIT AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-3983
Practice Address - Country:US
Practice Address - Phone:630-627-3930
Practice Address - Fax:630-627-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190249711223P0300X
IL0190149721223P0300X
IL0190302001223P0300X
IL060-003629261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty