Provider Demographics
NPI:1942322664
Name:MADISON PINE DENTAL
Entity Type:Organization
Organization Name:MADISON PINE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:POULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-287-3939
Mailing Address - Street 1:5470 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4031
Mailing Address - Country:US
Mailing Address - Phone:773-287-3939
Mailing Address - Fax:773-287-2573
Practice Address - Street 1:5470 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4031
Practice Address - Country:US
Practice Address - Phone:773-287-3939
Practice Address - Fax:773-287-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty