Provider Demographics
NPI:1669871463
Name:CALDIERARO FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:CALDIERARO FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:CALDIERARO
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-635-8333
Mailing Address - Street 1:332 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1822
Mailing Address - Country:US
Mailing Address - Phone:618-254-3355
Mailing Address - Fax:
Practice Address - Street 1:332 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1822
Practice Address - Country:US
Practice Address - Phone:618-254-3355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190277031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty