Provider Demographics
NPI:1053611319
Name:JARDELEZA, ANNE MARIE ROMAN (DDS)
Entity type:Individual
Prefix:
First Name:ANNE MARIE
Middle Name:ROMAN
Last Name:JARDELEZA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 N SPAULDING AVE
Mailing Address - Street 2:UNIT #6
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-9530
Mailing Address - Country:US
Mailing Address - Phone:847-323-3405
Mailing Address - Fax:
Practice Address - Street 1:624 W VETERANS PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-4567
Practice Address - Country:US
Practice Address - Phone:630-553-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319.017302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist