Provider Demographics
NPI:1194755389
Name:CANNIZZO, GREGORY ROSARIO (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ROSARIO
Last Name:CANNIZZO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5434
Mailing Address - Country:US
Mailing Address - Phone:815-344-2282
Mailing Address - Fax:815-344-5815
Practice Address - Street 1:3617 MUNICIPAL DRIVE
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7010
Practice Address - Country:US
Practice Address - Phone:815-344-2282
Practice Address - Fax:815-344-5815
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190207711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL300010958OtherTIN NUMBER