Provider Demographics
NPI:1255326856
Name:YACCINO, JOHN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:YACCINO
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 1:779 WHITE HORSE LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6833
Mailing Address - Country:US
Mailing Address - Phone:618-628-9907
Mailing Address - Fax:
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:375 DENTAL SQUADRON
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-6667
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN