Provider Demographics
NPI:1528474681
Name:METROSMILES - WAUKEGAN DENTAL PC
Entity type:Organization
Organization Name:METROSMILES - WAUKEGAN DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOS
Authorized Official - Middle Name:
Authorized Official - Last Name:TSALIAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-331-0901
Mailing Address - Street 1:4842 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2531
Mailing Address - Country:US
Mailing Address - Phone:708-222-8302
Mailing Address - Fax:
Practice Address - Street 1:458 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-3149
Practice Address - Country:US
Practice Address - Phone:847-331-0901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:METROSMILES - CICERO DENTAL, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-09
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty