Basic Information
Provider Information | |||||||||
NPI: | 1700863552 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIHALOPULOS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 513 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ANNA | ||||||||
State: | IL | ||||||||
PostalCode: | 629061668 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6188334471 | ||||||||
FaxNumber: | 6188338878 | ||||||||
Practice Location | |||||||||
Address1: | 103 N. APPLEKNOCKER | ||||||||
Address2: |   | ||||||||
City: | COBDEN | ||||||||
State: | IL | ||||||||
PostalCode: | 629202117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6188934005 | ||||||||
FaxNumber: | 6188931476 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 05/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 03/31/2006 | ||||||||
NPIReactivationDate: | 05/01/2006 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 019-026916 | IL | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 019-026916 | 05 | IL |   | MEDICAID |