Provider Demographics
NPI:1497025324
Name:FRED J. MARCHESE DDS, LTD
Entity Type:Organization
Organization Name:FRED J. MARCHESE DDS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARCHESE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-343-6065
Mailing Address - Street 1:1440 W NORTH AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1422
Mailing Address - Country:US
Mailing Address - Phone:708-343-6065
Mailing Address - Fax:708-343-6287
Practice Address - Street 1:1440 W NORTH AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1422
Practice Address - Country:US
Practice Address - Phone:708-343-6065
Practice Address - Fax:708-343-6287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019113261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental