Provider Demographics
NPI:1114941549
Name:VERSACI, VINCENT T (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:T
Last Name:VERSACI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4471 LAWN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1565
Mailing Address - Country:US
Mailing Address - Phone:708-246-6006
Mailing Address - Fax:708-246-6018
Practice Address - Street 1:4471 LAWN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1565
Practice Address - Country:US
Practice Address - Phone:708-246-6006
Practice Address - Fax:708-246-6018
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice