Provider Demographics
NPI:1841712536
Name:MITSOS, JAMES ROBERT (DMD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:MITSOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10759 WINTERSET DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-1106
Mailing Address - Country:US
Mailing Address - Phone:708-580-0404
Mailing Address - Fax:
Practice Address - Street 1:10759 WINTERSET DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-1106
Practice Address - Country:US
Practice Address - Phone:708-580-0404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332771223G0001X
IL0190313361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty