Provider Demographics
NPI:1497814842
Name:MASCORRO, EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:MASCORRO
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 1:4444 SOUTH ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632
Mailing Address - Country:US
Mailing Address - Phone:773-254-0303
Mailing Address - Fax:773-254-5040
Practice Address - Street 1:4444 SOUTH ARCHER
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632
Practice Address - Country:US
Practice Address - Phone:773-254-0303
Practice Address - Fax:773-254-5040
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist