Healthcare Provider Details

I. General information

NPI: 1487694097
Provider Name (Legal Business Name): RICHARD P. MARTINO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N WESTMORELAND RD SUITE 208
LAKE FOREST IL
60045-1674
US

IV. Provider business mailing address

900 N WESTMORELAND RD SUITE 208
LAKE FOREST IL
60045-1674
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-3390
  • Fax: 847-234-3391
Mailing address:
  • Phone: 847-234-3390
  • Fax: 847-234-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: