MEDICARE: ROBERT T MISERENDINO DDS 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	261QD0000X	Dental Clinic/Center	019015140	IL

General Provider Information

NPI Number	:	1457583536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT T MISERENDINO DDS LTD

Provider Business Mailing Address
First Line	:	8535 W 79TH ST
Second Line	:
City	:	JUSTICE
State	:	IL
Zip	:	60458-2281
Country	:	US
Telephone Number	:	708-458-7552
Fax Number	:

Provider Business Practice Location Address
First Line	:	8535 W 79TH ST
Second Line	:
City	:	JUSTICE
State	:	IL
Zip	:	60458-2281
Country	:	US
Telephone Number	:	708-458-7552
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT MISERENDINO
Credential	:	D.D.S.
Telephone Number	:	708-458-7552

Provider Enumeration Date	:	08/21/2009
Last Update Date	:	08/21/2009

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