Provider Demographics
NPI:1265411276
Name:CANZONA, JOSEPH E (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:E
Last Name:CANZONA
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 RIDGE AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2455
Mailing Address - Country:US
Mailing Address - Phone:847-328-8899
Mailing Address - Fax:847-328-3545
Practice Address - Street 1:2500 RIDGE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2455
Practice Address - Country:US
Practice Address - Phone:847-328-8899
Practice Address - Fax:847-328-3545
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21-0007621223S0112X
IL19-135671223S0112X
IL36-0648581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILTAX IDOther36-3349069
ILTAX IDOther36-3349069