Provider Demographics
NPI:1649336702
Name:JACONETTI, DANIEL LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LOUIS
Last Name:JACONETTI
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 1:7601 W MONTROSE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706-1000
Mailing Address - Country:US
Mailing Address - Phone:708-453-8700
Mailing Address - Fax:708-453-1564
Practice Address - Street 1:7601 W MONTROSE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-1000
Practice Address - Country:US
Practice Address - Phone:708-453-8700
Practice Address - Fax:708-453-1564
Is Sole Proprietor?:No
Enumeration Date:2006-12-30
Last Update Date:2014-04-15
Deactivation Date:2007-04-16
Deactivation Code:
Reactivation Date:2014-03-03
Provider Licenses
StateLicense IDTaxonomies
IL019-0183801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice