Provider Demographics
NPI:1912124660
Name:MICALETTI, JOHN (DDS, MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MICALETTI
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 55TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-1593
Mailing Address - Country:US
Mailing Address - Phone:630-789-0900
Mailing Address - Fax:630-789-3861
Practice Address - Street 1:115 55TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-1593
Practice Address - Country:US
Practice Address - Phone:630-789-0900
Practice Address - Fax:630-789-3861
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics