Healthcare Provider Details

I. General information

NPI: 1831869809
Provider Name (Legal Business Name): MARINHO DEL SANTO JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 BARRON BLVD
GRAYSLAKE IL
60030-3314
US

IV. Provider business mailing address

PO BOX 1881
MILWAUKEE WI
53201-1881
US

V. Phone/Fax

Practice location:
  • Phone: 224-371-7477
  • Fax:
Mailing address:
  • Phone: 414-288-0788
  • Fax: 414-288-0678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20936875
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019034607
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.003410
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: