Healthcare Provider Details

I. General information

NPI: 1194792911
Provider Name (Legal Business Name): VICTOR CIMINO MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S WASHINGTON AVE
PARK RIDGE IL
60068-4267
US

IV. Provider business mailing address

22 S WASHINGTON AVE
PARK RIDGE IL
60068-4267
US

V. Phone/Fax

Practice location:
  • Phone: 847-268-3910
  • Fax: 708-327-3463
Mailing address:
  • Phone: 847-268-3910
  • Fax: 847-897-3118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021002374
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number36091195
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: