Provider Demographics
NPI:1629130620
Name:CANNIZZARO, PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:CANNIZZARO
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 1:3006 S. DESPLAINES AVE.
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546
Mailing Address - Country:US
Mailing Address - Phone:708-447-8385
Mailing Address - Fax:708-447-8400
Practice Address - Street 1:3006 DESPLAINES AVE
Practice Address - Street 2:
Practice Address - City:NORTH RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1861
Practice Address - Country:US
Practice Address - Phone:708-447-8385
Practice Address - Fax:708-447-8400
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A133211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice