Healthcare Provider Details

I. General information

NPI: 1508548793
Provider Name (Legal Business Name): ZACHARY ROBERT SANTORO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COLLEGE AVE
ALTON IL
62002-4742
US

IV. Provider business mailing address

3238 CHARLOTTE CT APT C
ALTON IL
62002-4894
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-7000
  • Fax:
Mailing address:
  • Phone: 239-961-1265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number019.033858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: