Provider Demographics
NPI:1740292572
Name:SEVERINO, ANTOINETTE MARIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTOINETTE
Middle Name:MARIEL
Last Name:SEVERINO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9435 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1849
Mailing Address - Country:US
Mailing Address - Phone:708-485-0016
Mailing Address - Fax:630-922-0832
Practice Address - Street 1:9435 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1849
Practice Address - Country:US
Practice Address - Phone:708-485-0016
Practice Address - Fax:630-922-0832
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice