Provider Demographics
NPI:1336125475
Name:VACCARELLO, RICK DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:DOUGLAS
Last Name:VACCARELLO
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 1:71 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1004
Mailing Address - Country:US
Mailing Address - Phone:312-322-0567
Mailing Address - Fax:
Practice Address - Street 1:1504 W NORWOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2415
Practice Address - Country:US
Practice Address - Phone:773-293-7986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR5323Medicaid