1376771345 NPI number — DR. FRED PETER BIASIELLO III D.D.S.

Table of content: DR. FRED PETER BIASIELLO III D.D.S. (NPI 1376771345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376771345 NPI number — DR. FRED PETER BIASIELLO III D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIASIELLO
Provider First Name:
FRED
Provider Middle Name:
PETER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376771345
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 E ALGONQUIN RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
ARLINGTON HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60005-4373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-640-1112
Provider Business Mailing Address Fax Number:
847-510-0548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5445 GRAND AVE
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
GURNEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60031-1725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-244-2775
Provider Business Practice Location Address Fax Number:
847-244-2777
Provider Enumeration Date:
06/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019027965 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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