Provider Demographics
NPI:1154483907
Name:CANNIZZARO, RONALD ANGELO (DDS)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:ANGELO
Last Name:CANNIZZARO
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 1:545 RIDGEMOOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527
Mailing Address - Country:US
Mailing Address - Phone:630-654-1869
Mailing Address - Fax:708-255-5524
Practice Address - Street 1:545 RIDGEMOOR DRIVE
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527
Practice Address - Country:US
Practice Address - Phone:630-654-1869
Practice Address - Fax:708-255-5524
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019014811122300000X
IL0210008991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist