Provider Demographics
NPI:1952453979
Name:MARIETTA A BUFALINO INC
Entity Type:Organization
Organization Name:MARIETTA A BUFALINO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIETTA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUFALINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-397-6060
Mailing Address - Street 1:4005 1 2 ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008
Mailing Address - Country:US
Mailing Address - Phone:847-397-6060
Mailing Address - Fax:847-397-6063
Practice Address - Street 1:4005 1 2 ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008
Practice Address - Country:US
Practice Address - Phone:847-397-6060
Practice Address - Fax:847-397-6063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190190691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019019069OtherSTATE LICENSE