Healthcare Provider Details

I. General information

NPI: 1982724589
Provider Name (Legal Business Name): RICHARD A. GUACCIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E US HIGHWAY 30
SCHERERVILLE IN
46375-2117
US

IV. Provider business mailing address

124 E US HIGHWAY 30
SCHERERVILLE IN
46375-2117
US

V. Phone/Fax

Practice location:
  • Phone: 219-865-3050
  • Fax: 219-865-3431
Mailing address:
  • Phone: 219-865-3050
  • Fax: 219-865-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12006450
License Number StateIN

VIII. Authorized Official

Name: DR. RICHARD A GUACCIO
Title or Position: PRESIDENT
Credential: DDS
Phone: 219-865-3050