Provider Demographics
NPI:1346407178
Name:COLLETTI, MICHAEL T (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
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 1:237 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2647
Mailing Address - Country:US
Mailing Address - Phone:630-620-8304
Mailing Address - Fax:630-620-8759
Practice Address - Street 1:237 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2647
Practice Address - Country:US
Practice Address - Phone:630-620-8304
Practice Address - Fax:630-620-8759
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019019118OtherLICENSE NUMBER