Healthcare Provider Details

I. General information

NPI: 1215537113
Provider Name (Legal Business Name): JOSE A VILLANUEVA IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

470 PFINGSTEN RD
NORTHBROOK IL
60062-2506
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7555
  • Fax:
Mailing address:
  • Phone: 847-208-4706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002599-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: