MEDICARE: JOHN PETRUCCI DDS

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	019019714	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346407335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN PETRUCCI DDS

Provider Business Mailing Address
First Line	:	328 E ARMY TRAIL RD
Second Line	:
City	:	GLENDALE HTS
State	:	IL
Zip	:	60139
Country	:	US
Telephone Number	:	630-924-5579
Fax Number	:

Provider Business Practice Location Address
First Line	:	328 E ARMY TRAIL RD
Second Line	:
City	:	GLENDALE HTS
State	:	IL
Zip	:	60139
Country	:	US
Telephone Number	:	630-924-5579
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN PETRUCCI
Credential	:	DDS
Telephone Number	:	630-924-5579

Provider Enumeration Date	:	05/19/2008
Last Update Date	:	05/19/2008

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