Healthcare Provider Details

I. General information

NPI: 1356492276
Provider Name (Legal Business Name): CARMELLA B PERRY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 FLOSSMOOR RD
FLOSSMOOR IL
60422-1141
US

IV. Provider business mailing address

2711 FLOSSMOOR RD
FLOSSMOOR IL
60422-1141
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-9755
  • Fax: 707-799-8377
Mailing address:
  • Phone: 708-799-9755
  • Fax: 707-799-8377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019019877
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019019877
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: