Provider Demographics
NPI:1891887956
Name:SCHAUMBURG ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:SCHAUMBURG ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-882-9448
Mailing Address - Street 1:999 N PLAZA DR STE 102
Mailing Address - Street 2:SUITE 2N
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-5403
Mailing Address - Country:US
Mailing Address - Phone:847-882-9448
Mailing Address - Fax:847-882-9496
Practice Address - Street 1:999 N PLAZA DR STE 102
Practice Address - Street 2:SUITE 2N
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5403
Practice Address - Country:US
Practice Address - Phone:847-882-9448
Practice Address - Fax:847-882-9496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021001611 DR BANAKIS1223S0112X
IL021000892 DR DOEPFLE1223S0112X
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
675640Medicare UPIN
241210Medicare UPIN
U36156Medicare UPIN