Healthcare Provider Details

I. General information

NPI: 1619538485
Provider Name (Legal Business Name): JOHN PERISIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E MAIN ST
ST CHARLES IL
60174-2133
US

IV. Provider business mailing address

106 E HANOVER PL
PEORIA IL
61614-2120
US

V. Phone/Fax

Practice location:
  • Phone: 630-377-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.032202
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: