Provider Demographics
NPI:1922739648
Name:PIZZO, JACKSON M (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:M
Last Name:PIZZO
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 1:12222 S IL ROUTE 47
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9628
Mailing Address - Country:US
Mailing Address - Phone:224-654-6920
Mailing Address - Fax:
Practice Address - Street 1:12222 S IL ROUTE 47
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9628
Practice Address - Country:US
Practice Address - Phone:224-654-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033824122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist