Healthcare Provider Details

I. General information

NPI: 1144399593
Provider Name (Legal Business Name): ANDREW L. MARCHESE JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 STATE RD
BURBANK IL
60459-2051
US

IV. Provider business mailing address

5635 STATE RD
BURBANK IL
60459-2051
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-9200
  • Fax:
Mailing address:
  • Phone: 630-832-5623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19-17914
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: