Provider Demographics
NPI:1649602632
Name:DEMP FERN MG DENTAL CORP.
Entity type:Organization
Organization Name:DEMP FERN MG DENTAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:KANELLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-391-7529
Mailing Address - Street 1:1112 INDIAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3225
Mailing Address - Country:US
Mailing Address - Phone:847-832-1684
Mailing Address - Fax:847-832-1687
Practice Address - Street 1:6223 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2818
Practice Address - Country:US
Practice Address - Phone:847-966-8000
Practice Address - Fax:847-832-1687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental