Provider Demographics
NPI:1467524769
Name:MACKENBACH, JOHN C
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:MACKENBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 S BLOOMINGDALE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1466
Mailing Address - Country:US
Mailing Address - Phone:630-894-5180
Mailing Address - Fax:630-894-1148
Practice Address - Street 1:183 S BLOOMINGDALE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1466
Practice Address - Country:US
Practice Address - Phone:630-894-5180
Practice Address - Fax:630-894-1148
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice