Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | IL | |
N | 1223P0106X | Oral and Maxillofacial Pathology | IL | |
N | 1223S0112X | Oral and Maxillofacial Surgeon | IL |
NPI | 1487694097 |
---|---|
Provider Name | Dr. Richard P. Martino |
First Address | Lake Forest, IL 60045-1674 |
Second Address | Lake Forest, IL 60045-1674 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T37088 | (02) | IL |