Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | A11318 | IL |
NPI | 1003072844 |
---|---|
Provider Name | Dr. Jack Carmen Sasso |
First Address | Palos Hgts, IL 60463-1188 |
Second Address | Palos Hgts, IL 60463-1188 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2008 |
Last Update Date | 31/07/2008 |