Provider Demographics
NPI:1952455107
Name:FORMELLER, JOHN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:FORMELLER
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 1:1220 MEADOW RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-3698
Mailing Address - Country:US
Mailing Address - Phone:847-272-9666
Mailing Address - Fax:
Practice Address - Street 1:1220 MEADOW RD
Practice Address - Street 2:SUITE 204
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-3698
Practice Address - Country:US
Practice Address - Phone:847-272-9666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist