Provider Demographics
NPI:1508262544
Name:JOHN M DOMANICO, D.D.S., P.C.
Entity Type:Organization
Organization Name:JOHN M DOMANICO, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOMANICO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-629-3530
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE522
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-629-3530
Mailing Address - Fax:312-629-3516
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE522
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-629-3530
Practice Address - Fax:312-629-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1295840304OtherNPPES.CMS.HHS.GOV
IL1962500348OtherNPPES.CMS.HHS.GOV