Healthcare Provider Details

I. General information

NPI: 1619412087
Provider Name (Legal Business Name): ARTISAN DENTAL GROUP OF ILLINOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 12/21/2016
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: 847-934-4200
  • Fax: 847-934-4294
Mailing address:
  • Phone: 847-934-4200
  • Fax: 847-934-4294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019019961
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019019847
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019021223
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021001430
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021001354
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021001510
License Number StateIL

VIII. Authorized Official

Name: DR. DONNA MADDALOZZO
Title or Position: PRESIDENT/CO-OWNER
Credential: DDS, M.S.
Phone: 847-934-4280