Healthcare Provider Details

I. General information

NPI: 1336125475
Provider Name (Legal Business Name): RICK DOUGLAS VACCARELLO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 W NORWOOD ST
CHICAGO IL
60660-2415
US

IV. Provider business mailing address

71 W VAN BUREN ST
CHICAGO IL
60605-1004
US

V. Phone/Fax

Practice location:
  • Phone: 773-293-7986
  • Fax:
Mailing address:
  • Phone: 312-322-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3945
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: