NPIMap

Organization Active NPI

Periodontal Medicine and Surgical Specialists, LLC

  • Periodontics
  • Chicago, IL
National Provider Identifier
1386098390
Registry record updated Dec 23, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
License
021001938 Issued in IL
Legal business name
PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC
Practice address
1009 W Webster Ave
Chicago, IL 60614-3502
Phone
(630) 627-3930
NPI assigned
Apr 15, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 23, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
George Mandelaris, DDS, MS
Title
President
Phone
(630) 627-3930

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223P0300X 021001938 IL Primary
PeriodonticsGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223P0300X 021002676 IL
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223S0112X 021002351 IL
Dental Clinic/Center 261QD0000X

Addresses

Primary practice location

1009 W Webster Ave
Chicago, IL 60614-3502

Mailing address

1S224 Summit Ave
Suite 205
Oakbrook Terrace, IL 60181-3983
Phone (630) 627-3930

Other names 1

  • Periodontal Medicine and Surgical Specialists, LTD Former legal business name

National Provider Directory

National Provider Directory
Tax ID family
Periodontal Medicine and Surgical Specialists LLC4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1460678400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1482451200000",
    "number": "1386098390",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1S224 SUMMIT AVE",
            "address_2": "SUITE 205",
            "city": "OAKBROOK TERRACE",
            "state": "IL",
            "postal_code": "601813983",
            "telephone_number": "630-627-3930"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1009 W WEBSTER AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606143502",
            "telephone_number": "630-627-3930"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PERIODONTAL MEDICINE AND SURGICAL SPECIALISTS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-04-15",
        "last_updated": "2016-12-23",
        "status": "A",
        "authorized_official_last_name": "MANDELARIS",
        "authorized_official_first_name": "GEORGE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "630-627-3930",
        "authorized_official_credential": "DDS, MS"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "IL",
            "license": "021001938",
            "primary": true
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "IL",
            "license": "021002676",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "IL",
            "license": "021002351",
            "primary": false
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Periodontal Medicine and Surgical Specialists, LTD",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.