Healthcare Provider Details

I. General information

NPI: 1144604224
Provider Name (Legal Business Name): JAMES L DERRICO DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6448 COLLEGE RD
LISLE IL
60532-3290
US

IV. Provider business mailing address

6448 COLLEGE RD
LISLE IL
60532-3290
US

V. Phone/Fax

Practice location:
  • Phone: 630-983-8700
  • Fax: 630-983-8512
Mailing address:
  • Phone: 630-983-8700
  • Fax: 630-983-8512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.019814
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: JAMES L. DERRICO
Title or Position: OWNER
Credential: DDS
Phone: 630-983-8700