Provider Demographics
NPI:1598839797
Name:IANNAZZO, DANTE JOSEPH (DC)
Entity Type:Individual
Prefix:
First Name:DANTE
Middle Name:JOSEPH
Last Name:IANNAZZO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8079 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2817
Mailing Address - Country:US
Mailing Address - Phone:314-647-3847
Mailing Address - Fax:314-644-0449
Practice Address - Street 1:8079 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-2817
Practice Address - Country:US
Practice Address - Phone:314-647-3847
Practice Address - Fax:314-644-0449
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005029195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV08174Medicare UPIN