=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689744468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN JAMES DERANGO DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 1ST ST
-----------------------------------------------------
City | LA SALLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61301-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-223-9057
-----------------------------------------------------
Fax | 815-223-9248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 FIRST ST
-----------------------------------------------------
City | LASALLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-223-9057
-----------------------------------------------------
Fax | 815-223-9248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------