Healthcare Provider Details

I. General information

NPI: 1073036000
Provider Name (Legal Business Name): DANIEL ROSALES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1462 S RANDALL RD
ALGONQUIN IL
60102-5919
US

IV. Provider business mailing address

5804 N MARMORA AVE
CHICAGO IL
60646-6218
US

V. Phone/Fax

Practice location:
  • Phone: 708-695-6680
  • Fax:
Mailing address:
  • Phone: 773-750-0351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031283
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: