Provider Demographics
NPI:1578123360
Name:CELLINI, JOSEPH VINCENT (DMD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:VINCENT
Last Name:CELLINI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14340 JEFFERSON AVE APT 3S
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5367
Mailing Address - Country:US
Mailing Address - Phone:708-372-8128
Mailing Address - Fax:
Practice Address - Street 1:1005 E LASALLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2818
Practice Address - Country:US
Practice Address - Phone:574-367-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013214A122300000X
IL019.032070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist