Provider Demographics
NPI:1386098390
Name:PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Entity type:Organization
Organization Name:PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDELARIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:630-627-3930
Mailing Address - Street 1:1S224 SUMMIT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3983
Mailing Address - Country:US
Mailing Address - Phone:630-627-3930
Mailing Address - Fax:
Practice Address - Street 1:1009 W WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3502
Practice Address - Country:US
Practice Address - Phone:630-627-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210019381223P0300X
IL0210026761223P0300X
IL0210023511223S0112X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty