Provider Demographics
NPI:1235340373
Name:JOHN R. MARINUCCI, D.DS., LTD.
Entity Type:Organization
Organization Name:JOHN R. MARINUCCI, D.DS., LTD.
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROCCO
Authorized Official - Last Name:MARINUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-754-7505
Mailing Address - Street 1:414 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1739
Mailing Address - Country:US
Mailing Address - Phone:708-754-7505
Mailing Address - Fax:708-754-5576
Practice Address - Street 1:414 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1739
Practice Address - Country:US
Practice Address - Phone:708-754-7505
Practice Address - Fax:708-754-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190130591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty