Provider Demographics
NPI:1053397612
Name:CAPODICE, JACK JR (MD, DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:CAPODICE
Suffix:JR
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3515
Mailing Address - Country:US
Mailing Address - Phone:309-663-2526
Mailing Address - Fax:309-663-4788
Practice Address - Street 1:109 N REGENCY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3515
Practice Address - Country:US
Practice Address - Phone:309-663-2526
Practice Address - Fax:309-663-4788
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190227441223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBC0670174OtherDEA
ILBC0670174OtherDEA
ILF40908Medicare UPIN
ILBC0670174OtherDEA
IL210683Medicare ID - Type UnspecifiedMEDICARE GROUP #