Provider Demographics
NPI:1932129723
Name:VICIOSO, HENRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:VICIOSO
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 1:607 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60431-9701
Mailing Address - Country:US
Mailing Address - Phone:815-725-5991
Mailing Address - Fax:815-725-1983
Practice Address - Street 1:607 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60431-9701
Practice Address - Country:US
Practice Address - Phone:815-725-5991
Practice Address - Fax:815-725-1983
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice