Provider Demographics
NPI:1215198098
Name:COLLETTI, DOMINIC A (DDS)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:A
Last Name:COLLETTI
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 1:176 S BLOOMINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1404
Mailing Address - Country:US
Mailing Address - Phone:630-893-6200
Mailing Address - Fax:630-893-0474
Practice Address - Street 1:176 S BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1404
Practice Address - Country:US
Practice Address - Phone:630-893-6200
Practice Address - Fax:630-893-0474
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0201361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice