MEDICARE: GERALD M DONNELLI 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	019017607	IL

General Provider Information

NPI Number	:	1346474228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD M DONNELLI DDS

Provider Business Mailing Address
First Line	:	2028 E RIVERSIDE BLVD
Second Line	:	SUITE 210
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4804
Country	:	US
Telephone Number	:	815-877-4300
Fax Number	:	815-282-5306

Provider Business Practice Location Address
First Line	:	2028 E RIVERSIDE BLVD
Second Line	:	SUITE 210
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4804
Country	:	US
Telephone Number	:	815-877-4300
Fax Number	:	815-282-5306

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2009
Last Update Date	:	05/07/2009

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