=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407290208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VINCENT R. CRESCENZO, D.D.S., LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2013
-----------------------------------------------------
Last Update Date | 04/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 171 W 10TH ST SUITE 100
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-503-5001
-----------------------------------------------------
Fax | 708-503-5008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 171 W 10TH ST SUITE 100
-----------------------------------------------------
City | CHICAGO HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60411-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-503-5001
-----------------------------------------------------
Fax | 708-503-5008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VINCENT RALPH CRES
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 708-503-5001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------