PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC (NPI# 1386098390) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1386098390 |
| Entity Type | Organization |
| Organization Name | PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC |
| Other Organization Name | PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LTD |
| Practice Address |
1009 W Webster Ave Chicago IL 60614-3502 |
| Mailing Address |
1s224 Summit Ave Suite 205 Oakbrook Terrace IL 60181-3983 |
| Practice Telephone | 6306273930 |
| Mailing Telephone | 6306273930 |
| Enumeration Date | 2016-04-15 |
| Last Update Date | 2016-12-23 |
| Authorized Official Name | GEORGE MANDELARIS (PRESIDENT) |
| Authorized Official Telephone | 6306273930 |
| Authorized Official Credential | DDS, MS |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 261QD0000X |
Clinic/Center Specialization: Dental |
Ambulatory Health Care Facilities | ||
| N | 1223P0300X |
Dentist Specialization: Periodontics |
021002676 | IL | Dental Providers |
| N | 1223S0112X |
Dentist Specialization: Oral and Maxillofacial Surgery |
021002351 | IL | Dental Providers |
| Y | 1223P0300X |
Dentist Specialization: Periodontics |
021001938 | IL | Dental Providers |
| Other Name | Type Code |
|---|---|
| Periodontal Medicine and Surgical Specialists, LTD | Former Legal Business Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1811036718 | Periodontal Medicine and Surgical Specialists, LLC | Dentist | 1s224 Summit Ave, Suite 205, Oakbrook Terrace, IL 60181-3983 | 2007-02-06 |
| 1588703490 | Periodontal Medicine and Surgical Specialists, LLC | Dentist | 1875 Dempster St, Suite 250, Park Ridge, IL 60068-1186 | 2007-02-06 |
| Street Address |
1009 W WEBSTER AVE |
| City | CHICAGO |
| State | IL |
| Zip Code | 60614-3502 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1104867431 | Brian S Shah | Dentist | 1009 W Webster Ave, Store Front, Chicago, IL 60614-3502 | 2006-06-09 |
| 1386070167 | Brian Shah, Dds, Md, PC | Dentist | 1009 W Webster Ave, Chicago, IL 60614-3502 | 2013-09-24 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1487266516 | Taylor Connington | Pharmacist | 843 W Armitage Ave, Chicago, IL 60614 | 2020-08-19 |
| 1356975692 | Amarilis Diaz | Social Worker | Terry Hefter Associates, LLC, 1731 N. Marcey Suite 535, Chicago, IL 60614 | 2020-02-25 |
| 1457902975 | Michele Waggoner | Physical Therapist | 2515 N. Clark St, Chicago, IL 60614 | 2019-09-25 |
| 1669031936 | Justin Pomeroy | Acupuncturist | 1350 W. Schubert Ave., Chicago, IL 60614 | 2019-06-11 |
| 1801451547 | Amanda Harris | Counselor | 2451 N Lincoln Ave # 206, Chicago, IL 60614 | 2019-05-08 |
| 1780164574 | Danielle Trokey | Psychiatry & Neurology | 2515 N Clark St Ste 801, Chicago, IL 60614 | 2018-08-21 |
| 1841707353 | Madison Counseling Solutions LLC | Social Worker | 2502 N. Clark St., Chicago, IL 60614 | 2018-01-05 |
| 1386154011 | Allison Cooper Boyan | Occupational Therapist | 1640 N. Wells St., Unit 103, Chicago, IL 60614 | 2017-10-09 |
| 1245759653 | Eileen Davidson Siegel | Physician Assistant | 2073 N. Clybourn Ave., Chicago, IL 60614 | 2017-09-18 |
| 1447779814 | Elizabeth Hobart | Psychologist | 1800 W. Diversey Pkwy, Unit H, Chicago, IL 60614 | 2017-09-16 |
| Find all providers in zip 60614 | ||||
| Taxonomy Code | 1223P0300X |
| Grouping | Dental Providers |
| Classification | Dentist |
| Specialization | Periodontics |
| That specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues. |
| Notes: Source: Council on Dental Education and Licensure, American Dental Association |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1972145183 | Dental Dream Team Associates LLC Yetta Mccullom Sole Mbr | Dentist | 820 E 87th St Ste 201, Chicago, IL 60619-6256 | 2019-10-09 |
| 1508355678 | Periodontal Associates, LLP | Dentist | 845 N Michigan Ave Ste 940w, Chicago, IL 60611-2216 | 2018-05-04 |
| 1013304724 | Elliott T. Deweese | Dentist | 7447 W Talcott Ave., Suite 227, Chicago, IL 60631 | 2015-04-20 |
| 1417377417 | Kate Quinlin | Dentist | 939 W North Ave Ste 700, Chicago, IL 60642-7839 | 2014-04-17 |
| 1437597598 | Carmen Villasante Graves | Dentist | Rm.458 Mc 859, 801 S. Paulina St, Chicago, IL 60612 | 2013-06-11 |
| 1972781961 | Daniel M Weber | Dentist | 25 E Washington, #1125, Chicago, IL 60602 | 2008-02-01 |
| 1699809202 | Stephen P Russo | Dentist | 25 E. Washington St, Suite 1125, Chicago, IL 60602 | 2007-03-15 |
| 1366572802 | Christine M Gadia | Dentist | 223 W. Jackson Blvd, #1275, Chicago, IL 60606-6908 | 2007-03-06 |
| 1700915105 | Loyola M. Gleason | Dentist | 5945 S Pulaski Rd, Chicago, IL 60629-4550 | 2007-03-04 |
| 1790833192 | Thomas F. Schneider Jr. | Dentist | 4949 W Irving Park Rd Ste D, Chicago, IL 60641-2641 | 2007-01-08 |
| Find all providers in CHICAGO | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.