Provider Demographics
NPI:1316630635
Name:LAROCCA, MICHAEL C (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:LAROCCA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 LAKECLIFFE DR APT B
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-8364
Mailing Address - Country:US
Mailing Address - Phone:631-766-7671
Mailing Address - Fax:
Practice Address - Street 1:1350 E CHICAGO ST UNIT 4
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4724
Practice Address - Country:US
Practice Address - Phone:847-760-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034282122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist