Provider Demographics
NPI:1720710452
Name:DEMERTZIS, MARIELL (DMD)
Entity Type:Individual
Prefix:
First Name:MARIELL
Middle Name:
Last Name:DEMERTZIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N LA SALLE DR APT 4109
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8537
Mailing Address - Country:US
Mailing Address - Phone:224-616-7592
Mailing Address - Fax:
Practice Address - Street 1:4833 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1357
Practice Address - Country:US
Practice Address - Phone:847-673-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0338611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty