Provider Demographics
NPI:1558405225
Name:GRANDINETTI, SAMUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:GRANDINETTI
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 1:7417 LAVERGNE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3328
Mailing Address - Country:US
Mailing Address - Phone:847-673-8162
Mailing Address - Fax:
Practice Address - Street 1:7215 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-4386
Practice Address - Country:US
Practice Address - Phone:773-775-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190248451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice