Healthcare Provider Details

I. General information

NPI: 1982801759
Provider Name (Legal Business Name): NICHOLAS RUGGIERO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 MAIN ST STE A
ANTIOCH IL
60002-2181
US

IV. Provider business mailing address

1326 MAIN ST STE A
ANTIOCH IL
60002-2181
US

V. Phone/Fax

Practice location:
  • Phone: 847-395-6166
  • Fax:
Mailing address:
  • Phone: 847-395-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019020361
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: