Healthcare Provider Details

I. General information

NPI: 1255879946
Provider Name (Legal Business Name): ARTISAN DENTAL GROUP - RICHARD MADDALOZZO DDS MS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 N 1ST BANK DR
PALATINE IL
60067-8111
US

IV. Provider business mailing address

649 N 1ST BANK DR
PALATINE IL
60067-8111
US

V. Phone/Fax

Practice location:
  • Phone: 847-934-4280
  • Fax: 847-934-4294
Mailing address:
  • Phone: 847-934-4280
  • Fax: 847-934-4294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019021223
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019021223
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021001510
License Number StateIL

VIII. Authorized Official

Name: DR. RICHARD MADDALOZZO
Title or Position: MEMBER
Credential: D.D.S., M.S.
Phone: 847-934-4280