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General NPI Number Information
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NPI Number | 1336125475
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Entity Type | Individual
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Provider Name | RICK DOUGLAS VACCARELLO D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 12/20/2005
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Last Update Date | 10/06/2011
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Provider Practice Location Address
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Address Line | 1504 W NORWOOD ST
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City | CHICAGO
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State | IL
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Zip | 60660-2415
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Country | US
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Telephone | 773-293-7986
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Fax |
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Provider Business Mailing Address
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Address Line | 71 W VAN BUREN ST
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City | CHICAGO
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State | IL
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Zip | 60605-1004
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Country | US
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Telephone | 312-322-0567
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3945
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License Number State | WI
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