Healthcare Provider Details

I. General information

NPI: 1306830997
Provider Name (Legal Business Name): RUSSELL P SPINAZZE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N RIDGE AVE
MT PROSPECT IL
60056-2428
US

IV. Provider business mailing address

10 N RIDGE AVE
MT PROSPECT IL
60056-2428
US

V. Phone/Fax

Practice location:
  • Phone: 847-255-7080
  • Fax: 847-255-6931
Mailing address:
  • Phone: 847-255-7080
  • Fax: 847-255-6931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: