Healthcare Provider Details

I. General information

NPI: 1205973690
Provider Name (Legal Business Name): LOUIS B. SCANNICCHIO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N OAK PARK AVE
OAK PARK IL
60301-1304
US

IV. Provider business mailing address

110 N OAK PARK AVE
OAK PARK IL
60301-1304
US

V. Phone/Fax

Practice location:
  • Phone: 708-524-0101
  • Fax: 708-524-0164
Mailing address:
  • Phone: 708-524-0101
  • Fax: 708-524-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: