Provider Demographics
NPI:1336365642
Name:SISTO, JOHN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:SISTO
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 1:350 S NORTHWEST HWY
Mailing Address - Street 2:STE 118
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4216
Mailing Address - Country:US
Mailing Address - Phone:847-696-4848
Mailing Address - Fax:847-696-1609
Practice Address - Street 1:111 S. WASHINGTON
Practice Address - Street 2:STE 101
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-696-4848
Practice Address - Fax:847-696-1609
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190166561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL915390Medicare PIN