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General NPI Number Information
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NPI Number | 1497025324
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Entity Type | Organization
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Legal Business Name | FRED J. MARCHESE DDS, LTD
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Dates
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Enumeration Date | 01/10/2012
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Last Update Date | 01/10/2012
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Provider Practice Location Address
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Address Line | 1440 W NORTH AVE SUITE 304
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City | MELROSE PARK
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State | IL
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Zip | 60160-1422
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Country | US
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Telephone | 708-343-6065
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Fax | 708-343-6287
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Provider Business Mailing Address
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Address Line | 1440 W NORTH AVE SUITE 304
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City | MELROSE PARK
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State | IL
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Zip | 60160-1422
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Country | US
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Telephone | 708-343-6065
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Fax | 708-343-6287
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Authorized Official
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Title or Position | OWNER
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Name | DR. FRED J. MARCHESE
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Credential | D.D.S.
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Telephone | 708-343-6065
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 019019113
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License Number State | IL
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