MEDICARE: JOHN R. MARINUCCI, D.DS., LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019013059	IL

General Provider Information

NPI Number	:	1235340373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN R. MARINUCCI, D.DS., LTD.

Provider Business Mailing Address
First Line	:	414 DIXIE HWY
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-1739
Country	:	US
Telephone Number	:	708-754-7505
Fax Number	:	708-754-5576

Provider Business Practice Location Address
First Line	:	414 DIXIE HWY
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-1739
Country	:	US
Telephone Number	:	708-754-7505
Fax Number	:	708-754-5576

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN ROCCO MARINUCCI
Credential	:	D.D.S.
Telephone Number	:	708-754-7505

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	02/07/2012

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