Healthcare Provider Details

I. General information

NPI: 1134118110
Provider Name (Legal Business Name): ROBERT THOMAS MISERENDINO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8535 W 79TH ST
JUSTICE IL
60458-2281
US

IV. Provider business mailing address

8535 W 79TH ST
JUSTICE IL
60458-2281
US

V. Phone/Fax

Practice location:
  • Phone: 708-458-7552
  • Fax:
Mailing address:
  • Phone: 708-458-7552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019015140
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: