Provider Demographics
NPI:1619412087
Name:ARTISAN DENTAL GROUP OF ILLINOIS LLC
Entity Type:Organization
Organization Name:ARTISAN DENTAL GROUP OF ILLINOIS LLC
Other - Org Name:ARTISAN DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDALOZZO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:847-934-4280
Mailing Address - Street 1:649 N 1ST BANK DR
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-8111
Mailing Address - Country:US
Mailing Address - Phone:847-934-4200
Mailing Address - Fax:847-934-4294
Practice Address - Street 1:649 N 1ST BANK DR
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-8111
Practice Address - Country:US
Practice Address - Phone:847-934-4200
Practice Address - Fax:847-934-4294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190199611223G0001X
IL0190198471223G0001X
IL0190212231223G0001X
IL0210014301223P0300X
IL0210013541223P0300X
IL0210015101223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty