Provider Demographics
NPI:1750498234
Name:DISIMONI, RICHARD ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:DISIMONI
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 1:3381 W MAIN ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1008
Mailing Address - Country:US
Mailing Address - Phone:630-513-2121
Mailing Address - Fax:630-584-2366
Practice Address - Street 1:3381 W MAIN ST
Practice Address - Street 2:SUITE #3
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1008
Practice Address - Country:US
Practice Address - Phone:630-513-2121
Practice Address - Fax:630-584-2366
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist