=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588019012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SALERNO FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2016
-----------------------------------------------------
Last Update Date | 05/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6436 CERMAK RD
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-484-2710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6436 CERMAK RD
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-484-2710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JOHN A SALERNO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-484-2710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19-17774
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------