Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019026374 | IL |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 019026374 | IL |
NPI | 1396993945 |
---|---|
Provider Name | Dr. Michael Papadimitriou |
First Address | Chicago, IL 60659-4113 |
Second Address | Chicago, IL 60659-4113 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/09/2008 |
Last Update Date | 03/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
019026374 | (05) | IL |